Buckshaw 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

We found in the surgical service that safety was a priority across the service, with leaders embedding a culture of openness, transparency and collaboration. Leaders had effective systems in place to identify and respond to deteriorating patients in all areas, including the ward, operating theatre and recovery.

Staff took appropriate action to reduce the risk of avoidable harm. This included preventing pressure damage, venous thromboembolism (VTE) and falls. Safety checks were completed before surgery, with staff working together to ensure the correct patient received the correct treatment.

Staff managed medicines safely and followed established processes. Patients were protected from neglect, abuse and discrimination. Staff understood safeguarding responsibilities and acted appropriately to protect patients.

Staff gained informed consent prior to surgery. Where patients were unable to consent, staff involved those close to them and made decisions in the patient’s best interests, in line with legislation and guidance.

At our previous inspection, this key question was rated as good. At this inspection, the rating has remained good. Patients were protected from avoidable harm and received safe care.

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.

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.

Staff demonstrated a good understanding of incident reporting processes. They were able to describe what incidents and near misses to report, how to escalate concerns and said they felt supported in doing so.

Patient safety incidents were managed effectively. Staff told us they were involved in incident investigations and contributed to learning and outcomes. Incidents were investigated promptly, and staff demonstrated a good understanding of the duty of candour, including being open and honest with patients when things went wrong. Staff told us they were offered debriefs and appropriate support following serious incidents.

The service had a ‘Speak Up for Safety’ (SUFS) policy, and all staff received training on its use. This approach was promoted throughout the hospital, with posters displayed in clinical and staff areas. Staff were encouraged to challenge practice if they believed a patient safety risk was present.

All incidents were discussed at clinical governance meetings. Leaders told us that safety alerts, including ‘safety flash’ communications, were shared across the wider organisation to promote learning at local, regional and national levels. These updates included guidance on safeguarding, clinical practice and incident learning to improve care.

The surgical service had no Never Events in the last year. A 'Never Event' is defined as a serious, largely preventable patient safety incident that should not occur if existing national safety guidance and recommendations have been fully implemented.

A range of incidents had been reported and reviewed in line with organisational policy. Themes and trends were monitored using an electronic governance system. This system was used to track actions and ensure improvements were implemented. At the time of inspection, no recurring themes or trends were identified. We saw evidence on how the learning culture reduces safety concerns.

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.

Safety and continuity of care were prioritised throughout the patient pathway. Staff and patients described a well-organised surgical pathway from referral through to discharge.

At the initial pre-operative appointment, staff gathered comprehensive clinical information to support effective planning and reduce cancellations. Patients’ individual needs were considered, including preferred appointment times and accessibility. Leaders told us they adjusted clinic times, including offering evening appointments, to meet patient needs such as transport availability.

Staff carried out thorough pre-operative checks. This included reviewing allergies, nutritional needs, social circumstances and skin integrity. Staff calculated body mass index (BMI) and reviewed blood test results prior to theatre. These assessments informed care planning and ensured patients were clinically suitable for their surgery. Where concerns were identified, a patient’s operation was delayed or cancelled to maintain patient safety.

The hospital had clear admission criteria for patients undergoing operations. Staff completed and recorded all stages of the admission process using an electronic system. Patients were assessed by nursing staff, consultant and anaesthetist. The service offered a range of appointment types, including pre-assessment questionnaires, telephone consultations, face-to-face appointments and diagnostic investigations, to support patient access and individual needs.

We observed the patient journey during the inspection. Patients were registered by reception staff and escorted to an assessment pod. Staff confirmed patient identity and explained the operation and next steps. Patients were reviewed by the consultant and anaesthetist and given the opportunity to ask questions.

Staff used structured communication tools to support safe care. A handover that followed situation, background, assessment and recommendation (SBAR) was completed between clinical teams.

The World Health Organisation (WHO) surgical safety checklist was used prior to surgery to reduce the risk of harm. The WHO Surgical Safety Checklist is a nationally and internationally recognised patient safety tool designed to improve the safety of surgery. It supports clinical teams to consistently follow key safety steps before, during, and after surgery, reducing the risk of avoidable harm.

Following surgery, staff used SBAR and safety checklists to hand over care to recovery staff. Patients who underwent an operation had short recovery periods before returning to the ward area.

An electronic tracking system was used throughout the patient journey to maintain oversight and ensure safe transfer between areas. Some documentation was paper-based and stored securely in locked trolleys, while remaining easily accessible to staff in clinical areas.

Staff told us they felt confident to raise concerns using the ‘Speak Up for Safety’ (SUFS) approach if they identified risks within the pathway.

There were clear arrangements for patient transfers. One patient had been transferred to another hospital within the organisation for non-medical reasons in the past year. Policies were in place for both non-urgent transfers and the transfer of deteriorating patients to NHS acute hospitals. Staff told us patients were stabilised in high-care recovery before transfer where possible, and decisions were made by the ward doctor and consultant.

The physiotherapy team from outpatients supported patient discharge if required. They assessed patients’ needs, provided advice, equipment and referrals, and worked with families and care providers. Where patients required additional care, physiotherapists worked with the medical team to arrange transfer for further support.

Staff understood their roles and responsibilities to protect patients from abuse and neglect. We spoke with the safeguarding lead, who was trained to level 4 and had completed prevent training.

Safeguarding arrangements were supported by access to a Level 3 safeguarding practitioner in each clinical area. Compliance with Level 3 adult safeguarding training was 52% in theatres and 71% on the ward. Compliance with Level 3 children’s safeguarding training was 100%. All clinical staff were required to complete Level 2 safeguarding training, with compliance at 99%, and Level 1 safeguarding training, which also achieved 99% compliance.

Leaders told us, that the service has gone through a period of positive culture change in which a number of staff had left the provider and new staff were recently onboarded. This is the reason for the low figures in level 3 adult safeguarding. Leaders have active action plan in place to address this low figure.

Safeguarding policies for adults and children were in place and up to date. These included clear guidance, examples and flowcharts to support staff in identifying and reporting concerns. There were safeguarding noticeboards and resource boxes in each area, which provided information on referral processes and key contacts.

Although the service did not provide care for children, staff demonstrated an understanding of how to identify and respond to safeguarding concerns involving children if required.

Safeguarding was discussed daily during the safety huddle. Staff identified which team members were trained to level 3 in each area, and a level 4 trained practitioner was designated each day to provide leadership for complex concerns.

We saw evidence that safeguarding concerns were reported appropriately, including referrals to the local authority. Incidents were investigated to identify learning and whether changes to practice were required.

Leaders had oversight of safeguarding activity and monitored actions taken in response to concerns. They also had oversight of patients who lacked capacity and ensured appropriate safeguards were in place. Where safeguarding concerns prevented discharge, patients were appropriately transferred within the organisation to ensure their ongoing safety and care needs were met.

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 supported patients to do the things that mattered to them and promoted independence where appropriate.

We observed patients being kept informed about their care and treatment. Patients told us they received information about their surgery both at pre-operative appointments and on the day of treatment. Staff explained risks clearly and gave patients time to ask questions.

During pre-operative assessments, staff discussed patients’ individual needs. These were recorded on the electronic system, including alerts such as allergies. Staff and patients told us that these needs were reviewed and considered throughout the patient journey.

Following surgery, staff reassessed patients’ needs prior to discharge. The resident doctor supported discharge decisions, ensuring patients were able to mobilise safely and had appropriate medicines before leaving the hospital.

The service provided follow-up care through 48-hour telephone calls to check patients’ recovery. Patients were also given a telephone triage number to contact if they had any concerns after discharge.

Patients we spoke with on the day of inspection told us they felt listened to and supported by staff.

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 environment at Buckshaw Hospital was a day-case facility. During our inspection, we observed that all areas of the hospital were visibly clean and tidy. Corridors were free from clutter and well maintained. Waiting areas had comfortable seating which was in good condition. Accessible toilet facilities were available in all areas and met patients’ needs. Access to clinical areas was restricted through a swipe card system, and fire doors were unobstructed and closed appropriately.

The ward area consisted of four admission pods and eight recovery pods. These were individual rooms with glass partitions and privacy curtains to maintain patient dignity. Flooring throughout the area was well maintained and posed no risk to patients. Call bells and emergency alarms were in working order. Equipment had up-to-date portable appliance testing (PAT) labels.

A designated nurse champion was responsible for auditing equipment on the ward. We reviewed evidence of equipment checks and found processes were in place to ensure equipment was safe and ready for use.

Staff had completed competency assessments for the use of equipment. Moving and handling equipment, including hoists, was available and checked regularly. Staff told us they received annual training updates, and daily checks of equipment were completed. Evidence confirmed checks were carried out across ward and theatre areas.

We reviewed the resuscitation trolley and found it to be clean, organised and free from obstruction. However, one item was out of date. This was escalated immediately to staff, who told us a replacement had been ordered. The item remained available due to its potential use in an emergency. Management were informed of this concern.

In a ward store cupboard, we identified some equipment that was out of date, including a cannula, personal wipes and a syringe. We raised this with staff at the time, and the items were removed promptly. Staff told us the equipment was not used regularly. Management confirmed they would address this with the relevant teams to prevent recurrence.

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.

On the day of inspection, there were no concerns identified, with appropriate staffing, in the surgical service including on the ward.

Leaders told us staffing was managed flexibly. Staff could be redeployed across other locations to maintain safe staffing levels, and agency staff were used only as a last resort. There was an on-call system in place to escalate concerns out of hours, which included staffing issues. Staff said they received their rotas in advance and were able to request changes where needed.

The service had enough nursing and support staff with the appropriate skills, qualifications and experience to keep patients safe and provide effective care. The team included consultant surgeons and anaesthetists, resident doctors, theatre practitioners, an airway practitioner, recovery practitioners, registered nurses and health care assistants. Staffing levels were adjusted depending on the size and complexity of the patient list. Review of recent rotas showed no significant staffing gaps

Staff told us they received a structured induction when starting at the hospital. This included an induction booklet, essential training and orientation to the department. A buddy system was in place to support new staff, and learning materials, including videos, were available. Staff said they felt well prepared before working independently.

The service had made improvements to systems used to monitor staff training, including mandatory training. The electronic system allowed managers to track compliance and sent reminders to staff when updates were due. A designated staff member monitored training compliance and worked with managers to ensure completion.

The provider’s target for mandatory training was 95%, and compliance at the time of inspection was 98%. Training was completed annually or every 2 years, depending on the subject. For example, dementia awareness and equality and diversity training were at 99%, infection prevention and control at 98%, and autism and disability awareness at 91%. Staff told us they were given time to complete training and had access to role-specific training and refresher courses.

Consultants working at the hospital were required to meet practising privileges requirements, which included maintaining up-to-date compliance records. Evidence of compliance was reviewed regularly, and failure to meet requirements could result in suspension of practising privileges. A medical advisory committee (MAC) met quarterly, with representation from each speciality, to review performance and address any concerns.

Staff told us they had regular one-to-one meetings with managers where workload, performance and development opportunities were discussed. Staff gave examples of being supported to undertake further training, including university education. Some staff had progressed to teaching roles and shared their knowledge with colleagues.

Managers supported staff through annual appraisals and regular supervision. Where concerns about performance were identified, staff were supported with action plans, additional supervision and development opportunities.

Staff turnover and sickness rates had reduced over the last 12 months. Turnover decreased from 21% to 12%, and sickness rates reduced from 9% to 5%. The service had introduced initiatives to support staff wellbeing, including a mobile application to manage wellbeing and sickness, and access to counselling services.

Staff told us they felt the service was safe and said they were able to take appropriate breaks during their shifts. Patients also reported that their needs were met in a timely way. We observed staff responding promptly to call bells and providing kind and supportive care.

Medical care and surgery were provided by appropriately trained and experienced clinicians. A resident doctor was on site to support the ward and respond to emergencies. Physiotherapists were available to support patients following surgery. Although there was no on-site pharmacy service, support was provided by a neighbouring hospital within the organisation.

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 areas of Buckshaw Hospital were clean and free from dust, including clinical equipment. Domestic staff cleaned the hospital twice daily, with additional cleaning undertaken as required. ‘I am clean’ labels were available to indicate equipment had been cleaned; however, these were not used consistently. When we escalated, managers demonstrated that clinical staff completed daily cleaning schedules for equipment used on the ward and in theatres. Cleaning was also undertaken between patients and throughout the day when required.

The hospital had recently achieved a gold award through the Continuous Advancement Programme (CAP), an external audit assessing cleanliness standards. The service also undertook regular internal audits led by housekeeping teams and departmental managers.

There were appropriate systems for waste management. Clinical waste and sharps were disposed of safely, and bins and sharps containers were not overfilled. Staff followed infection prevention and control processes.

Staff understood how to manage clinical spills and knew how to escalate cleaning requirements to the housekeeping team. Housekeeping staff completed regular audits, including the use of ultraviolet light to assess cleanliness of high-touch areas.

Patients were screened for MRSA during pre-operative assessments to reduce the risk of infection. If patients required ongoing care due to infection, they would be transferred to an alternative hospital within the organisation or to an NHS acute hospital if clinically indicated.

There had been two reported post-operative infections in the previous 12 months. The two infections were investigated by the infection prevention nurse and appropriate action plans completed where appropriate.

Theatre cleaning and decontamination processes were carried out after each surgery, using checklists aligned with national guidance. Clinical areas were well organised, with clear separation of clean and used equipment. Sterile equipment was stored appropriately in designated clean storage areas.

The theatre environment was well maintained, free from clutter and all equipment was fit for purpose. We saw evidence that decontamination processes were completed after each surgery. A recent internal audit identified minor issues, including doors being left open and inappropriate use of adhesive materials. This audit achieved a score of 95%. On the day of inspection, we did not observe these concerns and were assured that regular audits were undertaken across the organisation.

Staff followed infection prevention and control procedures. We observed staff using appropriate personal protective equipment (PPE) throughout the hospital. Hand hygiene facilities were available and maintained, with hand gel accessible at key points. Staff adhered to ‘arms bare below the elbows’ guidance and demonstrated appropriate handwashing techniques.

Infection prevention and control policies were in place and aligned with national guidance. Staff had access to supporting policies, including those relating to linen management, hand hygiene and management of infectious diseases. An infection prevention and control lead provided oversight across the hospital sites.

The service completed regular water testing in theatre areas. This was carried out monthly by hospital staff, with additional quarterly testing undertaken by an external provider. There were no concerns identified regarding water safety.

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 happened.

Staff managed medicines safely. On the day of inspection, we saw evidence of safe prescribing, administration, storage and record keeping. Relevant policies, including those for medicines management and controlled drugs, were in place and accessible to staff.

We inspected medicine storage on the ward, recovery area and theatre and found all areas to be clean, well-organised and appropriately stocked. Medicines and discharge medications were stored correctly and were not mixed. Fridge and room temperatures were recorded daily to ensure medicines were stored within safe limits. All medicines were stored securely. Keys were held by the nurse in charge of the ward or theatre areas.

Staff were able to describe safe processes for the administration of medicines, including oral, intravenous and controlled drugs, as well as blood transfusions. We observed that medicines were prepared and administered safely at the point of care. Records relating to medicines management were accurate, complete and up to date.

The provider had a policy in place for patients who wished to self-administer their medication. This included guidance on assessment, storage, documentation and return of medicines. The policy also included consideration of patient capacity to safely manage their own medicines.

There was no on-site pharmacist, as the service operated as a day-case unit. However, pharmacy support was provided by a neighbouring hospital within the organisation. Clinicians reviewed patients’ medicines before and after surgery. We saw evidence of this in practice, including input from the resident doctor.

The service carried out regular medicines audits, including medicines administration, storage, controlled drugs, stock management, pain management and venous thromboembolism (VTE) prevention. A recent overall medicines audit scored 90%. Areas for improvement were identified, including record keeping and documentation of administration. Management had implemented actions to address these issues and improve compliance. No incidents relating to medicines management had been reported.

We checked equipment used to support medicines administration, including intravenous pumps and syringe drivers. These were available across ward, theatre and recovery areas, had been appropriately serviced and were in working order. Staff reported no concerns regarding access to equipment.

Oxygen cylinders were stored safely, checked daily and were within expiry dates. Cylinders contained adequate levels of oxygen and were stored correctly. Oxygen was also available in clinical areas.