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

The service managed patient safety incidents well as part of an integrated safety and governance structure. Staff recognised and reported incidents and near misses and clinical specialties monitored these continuously. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support. Staff had the required levels of training to safeguard vulnerable adults and knew what actions to take to keep people safe from avoidable harm and abuse. Well-tested systems and pathways maintained safe systems of care in which patient safety was prioritised and risk reduction assured. There was continuity of care when people moved between different specialties and other providers. The design, maintenance and use of facilities, premises, and equipment kept people safe. The service had enough staff with the right skills, training and experience who received effective support, supervision, and development. Staff worked together effectively to provide safe care that met people’s individual needs. The service controlled infection risk well. They kept equipment and the premises visibly clean. Staff used systems and processes to safely prescribe, administer, record and store medicines according to national evidence-based practice.

This service scored 78 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

There was a well-developed learning culture embedded in all aspects of the service. The culture and leadership of the provider was clinically led, and this was reflected in a clear patient safety ethos, which staff promoted in everything they did. The patient safety lead for outpatient centres was involved the investigation of all incidents and communicated findings with staff through governance structures and team meetings.

The patient safety and experience team worked across clinical specialties and departments, across all 3 London locations, to coordinate learning from incidents or near misses. Staff discussed errors and omissions in a culture that valued honesty and openness to drive improvement. This meant staff had an understanding of learning from services unrelated to their own, which they used to avoid risk and near misses in their own department.

Staff responded quickly to embed learning and recommendations from incidents. For example, the team replaced wired clinical equipment, used for heart assessments, to a wireless system to reduce the risk of falls.

The department displayed the current top 3 risks along with actions and mitigations as part of a transparent approach to learning. Staff said this approach helped them to keep safety learning as a key focus when providing care.

In the most recent quarter, staff reported 76 incidents, none of which resulted in patient harm. The provider reported these at service level, not at location level. This meant the 76 incidents occurred at a combination of the 3 London outpatient departments. The safety system meant staff learned from each incident regardless of where it occurred. As the team rotated between each site, the provider had assurance that all staff were up to date.

Staff used an electronic system to report incidents and track investigations. The system was integrated with governance and quality systems and meant staff responsible for safety and risk had continuous oversight of performance.

Outpatients operated seamlessly with other hospital services, including surgery, critical care, and inpatients. Consultants from each medical specialty provided care in the department and coordinated care and treatment plans with the full range of clinical services available. The hospital had an acute admissions unit (AAU), and consultants could admit patients directly in the event they deteriorated, or tests found an urgent need.

Nurses had developed a safety checklist, based on World Health Organisation (WHO) standards, to support minor procedures. This was part of a strategy to more fully utilise nursing skills in the outpatient setting. Consultants routinely used the WHO surgical safety checklist for minor operations and the provider audited the process on a monthly basis. In the previous 12 months, consultants achieved 94% compliance.

The provider had implemented the patient safety incident response framework (PSIRF) tool. The tool is part of an NHS England patient safety process, which the patient safety team and clinical educators had adapted to the outpatient environment. Patient safety leads established an investigation team for each incident, including a patient experience lead, and worked with the responsible clinician to follow Duty of Candour guidance.

Staff participated in periodic simulated emergency scenarios to test their knowledge and understanding. In the previous 12 months this included a simulated patient cardiac arrest whilst being scanned and a patient collapse prior to a scan. In each case clinical educators monitored staff performance, identified good practice, and gave feedback for improvement.

Staff demonstrated a holistic understanding of safeguarding risks and needs and acted quickly to keep people safe from harm. For example, the team had coordinated care for a patient who became increasingly confused in the department and who had attended without their carer.

Staff were trained to recognise signs of safeguarding needs, including those relating to social care. For example, they recognised a patient with full capacity was unkempt in appearance and was at risk of self-neglect. They liaised with the patient’s GP and provided a referral for greater community care team involvement.

Safeguarding training was comprehensive and included specific cultural information to support staff providing care for international patients. Clinicians were trained to recognise and act on evidence of female genital mutilation (FGM) and staff completed national ‘PREVENT’ training, which helped them identify the risk of radicalisation. All staff completed safeguarding training to level 3, including for children and young people. While staff did not treat children in this clinic, they completed training in recognition that young people may be present when accompanying an adult patient.

Staff worked with the global patient services team to secure safeguarding support for patients who lived outside of the UK. This included using discreet communication tools and identifying support services where they loved who could provide help when they returned.

All the staff we spoke with demonstrated a consistent knowledge of the principles and theories of safeguarding signs and risks and knew how to adapt care to keep people safe from harm. For example, staff understood the wide range of cultures and religions to which patients belonged and knew how to identify unusual or unacceptable risks outside of these norms. They had researched, tested, and implemented discreet communication systems for people to get help such as in instances of domestic abuse or trafficking.

The service had established risk management systems in place. Multidisciplinary by design, the clinically led systems were based on information sharing across the provider so that staff could learn from risks, near misses, and incidents in other departments. Outpatients’ nurses and healthcare assistants met daily before the start of service to discuss the treatments booked for the day, any capacity or staffing issues, and any pressures on the service. Colleagues from the provider’s 2 London locations joined the meeting, which helped to solve problems collaboratively and promoted clear understanding of risk.

Medical emergencies were infrequent in the outpatient setting. However, staff completed higher levels of training than necessary to ensure they could provide life-saving support to patients. For example, nurses completed immediate life support (ILS) training and healthcare assistants completed the bedside emergency assessment (BEACH) course. The provider supported extended development, and a nurse had successfully completed the advanced life support course. This nurse worked across the provider’s outpatient services, including this location, but was not attached to an individual clinic.

Clinical spaces were compliant with national standards, including the Department of Health and Social Care health building notices in relation to infection control in the built environment and flooring in healthcare environments.

Staff maintained equipment to keep people safe and respond to incidents in the department. This included a resuscitation trolley equipped with airway management equipment, oxygen, and a defibrillator. Biohazard spill kits were available to reduce the risk of contamination.

The health, safety, and fire manager led audits and compliance activities to ensure the service met the requirements of the Control of Substances Hazardous to Health (COSHH) Regulations. The department held an inventory of substances subject to COSHH and the health and safety team trained champions to carry out monthly audits. The health and safety team monitored results through a dashboard and were in the process of adopting a risk-based approach that would base the frequency of safety checks on each substance based on its individual level of risk.

Fire safety and security were managed at a building level and at departmental level by staff working there daily. All staff completed fire safety training, including practical evacuation training to support people using manual evacuation aids.

The provider used a clinically led model of care and employed most consultants in the service. This was a strategy to provide consistent standards of care and reduce the risks associated with relying on a practising privilege model.

All staff completed and maintained mandatory training. Training enabled nurses to work between specialties and clinics and provide consistently good clinical support. At the time of our inspection, compliance with training requirements was 97%. As outpatient staff worked across all 3 locations, the provider monitored training completion at service level and training records reflected the whole team.

Nurses worked across multidisciplinary clinics and specialties and had access to training to develop their competencies. For example, a laser protection supervisor supported nurses who had completed training to in the laser clinic.

Clinical educators worked closely with new staff during their training and induction to assess competencies and ensure training met their needs. They supported healthcare assistants and nurses to complete training in venepuncture, plastering/casting, wound management, managing nasogastric tubes, and phlebotomy. In addition, nurses had access to funded higher education courses and healthcare assistances were supported to complete the national care certificate.

Clinical nurse specialists operated nurse-led clinics and had appropriate training and good development opportunities. They worked within a scope of practice approved by a consultant in the medical specialty.

All staff completed an annual appraisal in addition to structured supervision and peer review. Appraisals empowered staff to identify their own future goals and implement plans to achieve them. Nurse and healthcare assistant appraisal incorporated a ‘whole view’ approach, which included feedback from consultants they worked with, peer reviews, and feedback from patients.

We observed effective infection prevention and control (IPC) and hazardous waste and sharps management. A dedicated housekeeping team maintained cleanliness and good hygiene in the environment and clinical staff used antibacterial procedures on equipment between patients and labelled them when they were safe for use. Good hand hygiene practices were embedded in practice and staff undertook regular training and auditing. In the previous 12 months staff averaged 96% compliance in hand hygiene standards against a target of 95%.

The infection control team use the NHS England national standards of healthcare cleanliness to carry out regular checks of practices in outpatients. Results were consistently good.

Staff worked within a range of policies and standard operating procedures (SOPs) that provided assurance of consistent standards. Policies were in place for outbreaks and emergencies, such as viral haemorrhagic fever.

The service monitored the presence of methicillin-resistant Staphylococcus aureus (MRSA), Clostridium difficile (C.Diff), and methicillin-sensitive Staphylococcus aureus (MSSA) in the department and tested patients where appropriate, such as before minor surgery. The department performed well in this measure and in the previous 12 months there had been no unit-acquired infections.

Standards of practice were reflected at provider level, which meant patient had assurance of high standards of practice when they moved between services. For example, the environment services team had been awarded gold in the national CAP (continuous achievement programme), recognising outstanding performance in cleaning and hygiene.

Nurse champions supported the IPC team to monitor standards and drive improvement. They undertook additional training and 2 had successfully completed the Institution of Occupational Safety and Health (IOSH) course.

The pharmacy team were responsible for the ordering and overall management of medicines in the department and hospital. They had established an electronic system that incorporated stock control, temperature monitoring, and secure access to authorised staff.

We saw consultants discuss long-term prescriptions, over-the-counter medicines, and alternative medicines on request during consultations. This was part of a comprehensive approach in which consultants gave patients time, space, and confidence to discuss their broader concerns, understanding that medical conditions are interconnected, and any information could support effective treatment.

Staff worked within the provider’s Controlled Drug (CD) management policy. This included a daily check of CDs by 2 nurses. This was recorded electronically, and the pharmacy team worked with the charge nurse to address any discrepancies. Nurse managers monitored weekly reports. In the previous 12 months there had been 4 discrepancy reports. All related to data entry issues, resulted in no loss or harm, and staff identified learning from each instance.

The hospital supported advanced nurse practitioners to complete non-medical prescribing training. Consultants and the pharmacy team provided supervision and peer support to ensure prescribing was safe and in line with guidance.