Cleveland Clinic London 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 looked for evidence that safety was a priority for everyone, and leaders embedded a culture of openness and collaboration. We checked that people were safe and protected from bullying, harassment, avoidable harm, neglect, abuse and discrimination. We also checked people’s liberty was protected where this was in their best interests and in line with legislation.

This was the first assessment of this service. We rated this key question good. This meant people were safe and protected from avoidable harm.

This service scored 66 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learned to continually identify and embed good practice.

Staff told us they were positively encouraged to raise concerns however minor, and that senior staff were approachable and took concerns seriously.

The service held daily huddles on the wards which fed into a departmental huddle which in turn fed into the organisational huddle. This meant information was fed from staff to leaders and back. Staff told us learning was shared at the daily huddle. The charge nurse on the post-anaesthesia care unit (PACU), told us there was a team brief in the morning huddle where the daily list, issues likely to arise and amber pathways for infection prevention and control (IPC) were discussed. This meant staff were aware where the risks were and would act accordingly.

Any moderate incident with physical harm was considered an incident of note. A ‘newsflash’ document was produced and sent to all departments to discuss in all departmental meetings. This shared the incident with staff, prompting team discussions to embed the learning. Learning was shared at a number of meetings, and we saw minutes to reflect this. For example, at the nursing leadership meeting an incident where a swab had been retained during surgery was reviewed.

The provider used the patient safety incident reporting framework (PSIRF) to investigated incidents and had produced a two-year patient safety incident response plan. All incidents, near misses, safety and improvements were reviewed through the governance structure with data presented to the quarterly integrated governance committee.

The provider had policies in place to support the governance around incidents, such as the safety alerts management procedure and freedom to speak up policy which meant staff had clear guidance to follow and clarify standards expected.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. Staff made sure there was continuity of care, including when people moved between different services.

Patients attended a pre-assessment appointment prior to surgery where screening and risk assessments were carried out to ensure patients clinical and cultural needs were met and electronic records were updated.

Multidisciplinary teams (MDT) worked together to safely plan and carry out surgical procedures. Complex procedures were discussed to determine what input was required from different specialities. In complex cases where a different specialist surgeon may be required during surgery; it was the providers policy to have that surgeon present at the hospital and not on call off site which meant the surgeon was available immediately. We reviewed a case where this had worked well, and a cardiac surgeon was present.

Patient flow throughout the hospital meant there were no delays transferring patients between services. Staff in the post-anaesthesia care unit (POCU) told us they were able to transfer patients to wards without delays.

A critical care outreach team was available 24 hours a day, seven days a week and on call rotas for emergency surgical provision involving a theatre standby team and diagnostic provision within an hour. An anaesthetist we spoke with told us they were part of this on-call rota.

Each surgical team were responsible for their own scheduling which meant specialist services could organise surgical lists depending upon the staff required for each procedure.

The medical director told us the hospital did not cancel procedures where possible. This meant the finishing time for staff was sometimes uncertain. This was under review with a theatre optimisation task group with an aim of improving this for staff while maintaining patient safety. At the time of our assessment this review had not started.

Staff understood how to escalate and raise safeguarding concerns and knew how to access the safeguarding policies and procedures. Any safeguarding information of concern was reviewed and actioned at the daily huddle, so all staff were aware of the concerns. Each ward had a dedicated safeguarding champion meaning immediate guidance was available and they would liaise with the registered manager if there were any concerns.

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All staff received training in safeguarding children and adults as part of their mandatory training. The level required was dependent upon role and this was outlined in the policy. All clinical staff were trained in safeguarding adults and children to level 3 as a minimum requirement. Staff we spoke with told us they had completed their training which included the mental capacity act, deprivation of liberty safeguards (DoLS) and female genital mutilation (FGM) and data showed 95% of staff had competed their training.

Best interest meetings were held regularly to assess what was in the best interest of a patient if they lacked capacity. An advocate was appointed to act on behalf of the patient and patients, their carers and relatives were included in the decision making. A neuro-psychology team worked with surgical patients in conjunction with the therapy teams to carry out capacity assessments which ensured there was an MDT approach with staff trained to review cognitive ability and the changes over time .

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The safeguarding committee fed into the quality and safety board and met on a quarterly basis. DoLS applications were reviewed along any other safeguarding concerns at the safeguarding committee which meant there was clear oversight and measures were proportionate.

The provider had several policies to help keep patients safe, including a safeguarding of children and young people policy and a Disclosure and Barring Service (DBS) policy. The five policies we reviewed were in date and referenced national guidance and legislation.

Staff understood how to recognise and manage risks. Prior to admission patients attended a pre-assessment appointment which included a review of patient’s medical history and undertaking routines tests such as infection control screening. Admission was signed off by the surgical consultant and infection control consultant, this ensured patients were assessed by a senior doctor with the knowledge to understand the risks.

As part of this assessment each patient had an American Society of Anaesthesiologists (ASA) physical status score calculated. This is a grading system used to assess patients’ health before surgery and identify any potential complications. Anyone with a risk of three or more on their ASA score had a further assessment using a surgical outcome risk tool (SORT) which estimated risk of death 30 days after surgery.

Staff used nationally recognised tools to help manage risk. For instance, staff used the national early warning score (NEWS) and Malnutrition screening tool (MUST) to continually assess patients and take the necessary action to reduce the risk. If the patients score hit a set criterion, staff could escalate the patient for additional support. If a patient’s NEWS score was four or higher, the critical care outreach team was contacted automatically. Staff told us the critical care outreach team were easy to access and available 24 hours a day, seven days a week.

Patients we spoke with told us they were well informed about their procedure during the pre-admission appointment and when they were admitted which helped manage their expectations and understand any risk involved.

Theatres were designed to be large and spacious with clear access. We saw clean areas for preparation, theatre kits, implants storage; all clearly labelled with key entry to prevent unauthorised access. Orthopaedic theatres had laminar flow, which is a way of generating continuous air flow of bacteria free air.

The area for storing emergency equipment was organised and there were clear signs for where things were stored. There was a critical care transfer bag with a daily check sheet which we found had been completed daily thought out November 2024. We checked the resuscitation trolley and saw the quick reference handbook and anaesthetic advice sheets in place. The defibrillator was checked and dated, and oxygen was securely stored on the trolley which meant equipment was readily available in the event of an emergency.

We saw the use of ‘I am clean’ stickers throughout our visit, and we reviewed daily check sheets that demonstrated cleaning audits had taken place. The daily checklist for the theatre fridge had not been completed on three days in November 2024. This meant there was no assurance on these days’ medicines had been stored at the right temperature. During the assessment we saw checklists were completed in paper form. Following the assessment the registered manager told us fridge temperatures were recorded electronically, and the head of pharmacy was automatically alerted when fridges were not within a safe range.

Theatres used a dosimeter badge board; a dosimeter badge is used to detect and measure the level of radiation staff have been exposed to. Each badge was personalised for each staff member to accurately reflect the levels they have been exposed to. This ensured staff were not over exposed to radiation keeping them safe.

The clinical engineering department recorded and tagged assets and were responsible for managing loan equipment. Nursing staff told us they were easy to contact and responsive when there had been an issue with equipment.

The medical devices committee identified the needs of the service and decided on new equipment. The committee was chaired by an anaesthetist and head of clinical engineering. The minutes included risks identified and added to the risk register with control measures in place.

Leaders in each area managed staffing rotas according to established safe staffing guidance. There was a safe staffing policy which referenced national guidance and best practice. Staffing levels were reviewed daily according to patient acuity. We observed, and were told by senior leaders, staffing went intentionally beyond guidelines and were always compliant with the safer nursing care tool (SNCT) and Association for Perioperative Practice (AfPP) guidance. This meant there was enough staff to look after patients safely.

The staff structure in theatres had a set minimum standard which could be increased depending on the complexity of the surgery. This was reviewed on a case-by-case basis, ensuring individual needs were met.

We observed staff allocations boards in theatres. It listed staff involved in the procedure and on call staff meaning it was clear to the team who should be there to safely carry out the procedure and who was available to additional assistance if required.

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Staff told us they were well supported by leadership to only carry out a procedure if they were fully staffed, and it was safe.

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Advance nurse practitioners and Clinical nurse specialists were able to consult on patients throughout their stay meaning patients had access to specialists when needed.

The medical director told us there were no medical or nursing vacancies. Rotas were provided six weeks in advance and gaps were fulfilled with bank staff. We were told the service had not used agency staff in over 18 months. This ensured staff knew the service and managers were confident they had staff with the right skills.

Practice educators were available in theatres and wards. Twice a month they ran training sessions on or how to prepare for a complex case. Staff we spoke with told us they were encouraged to access training for continuing professional development. One ODP demonstrated this by showing us the online portal where staff could access training in core competencies and simulations. Clinical staff had protected time for teaching sessions in the theatre environment. This meant staff could train together in the area they worked, giving context to the educational session.

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The provider had policies and procedures in place to support good infection prevention control practices. Policies we reviewed referenced national guidance and were in date. Staff we spoke with knew how to access the polices and guidance. Staff were sent a newsflash when an important policy update had been made. We saw the newsflash update for infection prevention and control around tuberculosis with points to note for staff.

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Throughout theatres, the anaesthetic room, PACU and the surgical wards we observed clean, accessible areas that were spacious, organised and well maintained. There was evidence of I am clean labels on equipment and all doors and walls were intact to maintain cleanliness. Hand washing sinks, towels, soap and hand gel were available throughout. Hand hygiene audits were carried out and showed compliance was 94% and staff were reminded in daily huddles about the importance of hand hygiene.

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Staff understood their roles and responsibilities towards infection prevention and control. We observed staff washing their hands and scrubbing in theatre, which is an enhanced way to wash hands and forearms prior to surgery and reduce the risk of infection. There was use of personal protective equipment such as, aprons, gloves, masks, scrubs, theatre clogs, visors and hats. These measures mitigated the risk of cross contamination.

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On the surgical wards we visited, we saw staff washing their hands and using hand gel between patients. The service used of disposable dignity curtains which were dated and replaced when soiled. Ward staff told us domestic staff were responsive and attended outside of cleaning rotas if needed.

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Sluices were clean and there were waste management arrangements in place for general and clinical waste. Sharps boxes were closed, dated and signed compliant with good practice.

The service used an outside agency to decontaminate surgical instruments to ensure they were safe to use.