Euxton Hall 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. Leaders had systems for identifying and responding to deteriorating patients on the ward, in the operating theatre and recovery. People received treatment and care to reduce the risk of avoidable harm, such as pressure damage, blood clots or falls. There were safety processes arranged before surgical procedures and operations started, with staff working together to ensure the right patient had the correct operation. Medicines were managed safely. Patients were safe from neglect, abuse and discrimination. Patient’s gave informed consent prior to procedures and where they were unable to consent, those close to them were involved in decisions made in their best interests.

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 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.

There was a provider incident reporting policy that was clear, comprehensive and had been reviewed on a regular basis.

Staff were encouraged to report incidents. The provider used an electronic system to record incidents across the hospital locations. These were monitored on the providers dashboard. In the 12 months prior to inspection, there had been 217 incidents reported that were graded according to their level of severity of which 169 were clinical incidents. There were 4 incidents graded in the highest severity level.

Themes and trends at the hospital were benchmarked across the locations with shared learning, to promote best practice.

The hospital had identified an increase in patient transfers. In response, staff had been involved in additional scenario‑based training and competency refreshers were completed.

We reviewed examples of incidents reported and found they had been investigated appropriately. We were given examples of where learning had been identified, shared and implemented such as Venous Thromboembolism prevention (VTE). VTE is when a clot in a deep vein, usually the leg, can travel to the lungs.

Learning from incidents was shared in team meetings as well as monitored in patient experience reports.

There had been no reported never events in the preceding year. Never events are serious, preventable safety incidents which should not occur if the available preventative measures are followed. They include things like wrong site surgery or foreign objects left in a person’s body after an operation.

Senior staff, at the hospital, reviewed and investigated incidents and shared any learning with staff and the provider. Incidents were reviewed fortnightly at their incident review meeting, where any actions were identified and monitored.

Serious incidents were reviewed for duty of candour, and if an after-action review or patient safety incident response (PSII) investigations were required. The patient safety incident reporting framework (PSIRF) focuses on learning from incidents and advocates patient involvement in the process. In the event of a patient safety incident, as well as verbal communication, the patient was provided with a booklet to explain the investigation process.

There was a provider ‘being open policy’ and a duty of candour framework. The duty of candour is a legal and professional obligation for health and social care providers to be open, honest, and transparent with patients. Staff, we spoke with, understood the duty of candour.

The providers ‘closing the loop’ process included the outcome, actions and sharing of incidents with staff.

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 areas of the hospital and between providers.

Patients were referred for care via GP’s, patient choice or consultants.

The providers pre-operative assessment framework included details of patient suitability for treatment at the hospital.

There was an exclusion criteria that staff followed when assessing patients. This framework set out where they had limitations in services and therefore minimised risks of complications by excluding some patients. For example, patients with high risk of needing additional support such as requiring recovery in a critical care or high dependency unit.

Patients requiring tests and investigations were given information to enable them to understand their surgery. Following initial consultation and referral to surgery, patients were required to attend for preoperative assessment to confirm their suitability for surgery at the hospital.

Pre-operative appointments were completed in a face-to-face appointment with a preoperative care nurse. Patients’ clinical history and presenting concerns were reviewed and recorded in the electronic system. Patients were given verbal explanations of what to expect between the appointment and date of admission for surgery. This was supported by a pack that included information about anaesthetics and fasting instructions with advice on which medicines to stop and for how long before surgery.

Advice was given regarding post-operative recovery including activity levels and pain relief. For certain surgeries, patients were given nasal gels and body washes to help prevent infection.

There were systems and processes to ensure the correct patients were treated throughout the patient journey. We observed the patient journey from admission on the ward to the operating theatre. Handover of patient information included identification checking.

The World Health Organisation (WHO) surgical safety check list was used. The WHO Surgical Safety Checklist is tool to reduce surgical errors, infections, and deaths. It facilitates communication and teamwork among theatre staff. We observed completion of the process.

Audits of the 5 steps to safer surgery were 100% compliant in March 2025 and September 2025. Stop before you block was also observed in theatres. Stop Before You Block (SBYB) is a safety process that includes that clinicians pause immediately before administering a regional nerve block to reconfirm the correct patient, site, and procedure to prevent "never event" wrong-side blocks. Audits we received of SBYB, were dated June 2025 and September 2025 with 100% compliance.

Leaders audited NatSSIPs compliance. National Safety Standards for Invasive Procedures (NatSSIPs) are standards designed to reduce patient safety incidents during invasive procedures, including surgeries, biopsies, and endoscopy. For management of histology, compliance ranged from 94% to 100% between April 2025 and September 2025. For instruments, compliance ranged from 96% to 99% between April 2025 and February 2026. For prosthesis, compliance ranged from 92% to 100% between March 2025 and February 2026.

The transfer of patients from the operating theatre to the recovery was managed safely, with the anaesthetist retaining responsibility for determining the readiness for transfer. Suitably skilled and qualified staff accompanied patients in all areas.

In the event of a patient deteriorating arrangements were made to transfer to a local NHS trust hospital for continuation of care. There was a standard operating procedure (SOP) for the emergency transfer of adult critically ill patients from independent sector to NHS critical care units for hospitals in the integrated care system and checklists to follow to support a safe transfer.

There was an additional process for inter-hospital transfers between provider locations with an independent ambulance provider.

There was a SOP for patient discharges. Information was recorded electronically to support verbal advice and leaflets were provided such as wound care, pain management, follow-up appointment or medication and anti-embolism stockings.

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.

There were provider policies for safeguarding adults at risk of abuse and neglect and safeguarding of children and young people.

Staff understood how to protect patients from abuse and the hospital worked with other agencies to do so. We were shared examples of safeguarding concerns that had been raised and reported. There was a grab bag that included a pack, flowcharts and contacts for local safeguarding services in addition to posters displayed. Staff received adult and children's safeguarding training.

Data showed that compliance with safeguarding adults level 1 and level 2 was 99%. Compliance with safeguarding children levels 1 and 2 was 99% and 100% for level 3.

Safeguarding training incorporated subjects such as female genital mutilation (FGM), prevent, mental capacity and modern slavery.

There was a safeguarding lead trained to level 4. The hospital could link with the local authority, police and mental health crisis teams if needed and safeguarding was discussed as part of governance meetings.

There had been no safeguarding incidents in the 12 months prior to inspection that met the threshold for a referral.

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.

Patient records were a combination of electronic and paper based and were kept securely.

Staff carried pocket guides that included information regarding a range of daily activities including risk assessments, pain management, safeguarding, fluid balance and observations.

There was a provider policy for recognition and management of the deteriorating patient that included management of sepsis.

At the pre‑operation appointment, staff carried out important checks to make sure patients were safe for surgery.

This included using the Malnutrition Universal Screening Tool (MUST), which helps identify if someone is undernourished, at risk of not getting enough nutrition, or overweight.

Staff also recorded an American Society of Anaesthesiologists (ASA). This is a simple rating system used to show how healthy a patient is before their operation and helps doctors understand any possible risks during surgery.

Staff assessed patients using National Early Warning Score 2 (NEWS2). This is a system used to assess, detect, and respond to acute clinical deterioration in adult patients. Audits of completion of NEWS2 ranged from 89% to 97% between November 2025 and March 2026.

Completion of falls prevention audit was completed in September 2025 with a compliance of 72%. An action plan was developed to improve compliance that included contacting all staff, the creation of ‘call, don’t fall posters’ in patient rooms and fall mats for those identified at risk of falls. An audit of patient records in February 2026 was 100% compliant.

The hospital worked with patients to understand and manage risks. Treatment and care met patients' needs in a way which was safe and supportive.

The patients we spoke with told us they felt listened to and they were involved in decisions about their care and 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.

Surgical services included a ward, two theatres and a preoperative clinic. The hospital detected and controlled potential risks in the care environment.

The design, maintenance and use of facilities, premises and equipment kept people safe.

The building was accessed by steps or a ramp with automatic doors at the entrance. Due to the age of the building space could be limited and some of the corridors were narrower than others, however; these were free form clutter.

Leaders and staff took steps to make sure equipment, facilities and technology supported the delivery of safe care. Where they were unable to do so, they mitigated the risks. The main building was Grade 2 listed meaning there could be challenges with maintenance.

The design of the environment followed national guidance. Where required, areas were secure and protected patients with access restricted by electronic keycards.

The environment of the ward and other areas used for patient care reduced the risk of patient harm, and included safe flooring, wet rooms and handrails. There had been recent refurbishments both on the ward and in theatres. The ward was bright, clean, and had spacious ensuite rooms.

Leaders ensured equipment was safe, well maintained, and ready to use. Staff carried out daily safety checks on specialist equipment, including anaesthetic machines, which were checked by operating department practitioners (ODPs). Emergency resuscitation trolleys were available in both the ward and theatres. An asset register was in place to track equipment and maintenance schedules, with some servicing provided through external contracts. In theatres, ambient temperatures were also regularly monitored.

An external audit of condition, appearance and maintenance scored 100% compliance in 2025.

Fire safety measures were in place across the hospital. Equipment was available and fire exits were clear and free from obstruction. The provider had a fire manual and a SOP about fire safety specific for the hospital. The fire alarms were linked to a fire emergency auto response service and daily hospital huddles identified fire marshals.

A fire risk assessment had been carried out September 2025 by an external organisation. There were recommendations made with some relating to the age of building. An action plan was in progress to address them.

Fire evacuation training was a mandatory requirement face to face and out of hours fire drills had taken place in July 2025 and October 2025 including a de-brief report.

Hazardous substances were stored safely, in theatres, and information about products was available to staff.

Patients could reach call bells. Call bells were positioned by patient beds, and staff showed patients how to use them to summon help. Patients told us that they were responded to promptly. The system had been upgraded as part of recent refurbishments.

Staff disposed of clinical waste safely, both inside and outside the building. Waste was segregated appropriately. Bins for sharps disposable were available and safely stored.

However, we saw that the hoist that was available for patient transfers was passed the date for servicing. We were told that it was used for training purposes only. The day following the onsite inspection the provider confirmed that the hoist was serviced that day and there was a plan for routine maintenance every six months.

We observed that some of the surgical positioning pads, in theatre, were showing signs of wear and tear. We escalated this on site and have been told that these were to be replaced.

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 hospital had enough clinical staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment.

New and temporary staff completed a full induction tailored for their role. Managers supported staff to develop and completed annual performance and development reviews (PDR’s) and clinical supervision of their work. Staff completed compliance for PDR’S was 93% overall at the time of inspection.

Managers reviewed the number and grade of registered nurses and assistants needed for each shift. The hospital was in the process of implementing a new safe staffing tool that incorporated patient acuity details. Theatre staffing was planned, based on activity. Between January 2026 and March 2026, there was 100% of staffing requirements. At times of short-term sickness, mitigations were in place to ensure safe numbers of staff to care for patients in theatre and on the ward.

Managers limited their use of bank staff and requested staff familiar with the service. Agency has been used adhoc during gaps in rotas whilst recruiting but usage had stopped at time of inspection.

Sickness for the hospital was an average 6% per month between March 2025 and Feb 2026 although there was an improving trend for early 2026. For the same time period the average turnover per month was 12%.

We saw notes from monthly team meetings and other general information were shared on notice boards with regular agenda updates that included operational updates, training, medicines and patient feedback.

Allied healthcare professionals (AHP’s), including physiotherapists and pharmacists formed an integral part of the patient care and treatment pathway and promoted recovery and rehabilitation.

Consultant surgeons and anaesthetists were subject to a full assessment through the practising privilege process. If there were any concerns with performance, there were processes to follow and if necessary, information would be shared with professional bodies as required.

Surgical procedures and clinical decisions were carried out by consultants. Patients were clear who the doctors involved in their treatment were.

The overnight and weekend provision was adequate, with access to the admitting consultant for advice or to attend, if necessary. Consultants were required to confirm that they were within 30 minutes or 20 miles of the hospital in case needed for patient review out of hours.

The hospital had formal arrangements for a resident doctor to be on site 24 hours a day when patients were receiving treatment and care.

Staff completed mandatory training and competencies required for their roles. There were clinical supervision sessions and opportunities to develop skills.

Registered nurses (RN’s) were required to complete immediate life support (ILS) training and acute illness management (AIM’s) training. All were either up-to-date or booked on to a course. In theatres the five operating department practitioners were required to complete advanced life support (ALS) to practice.

Managers had oversight of training. Attendance was monitored and escalated if any concern in monthly meetings

At the time of inspection, mandatory compliance was 95% for face-to-face training and 98% for e-Learning.

Staff were also required to complete competencies for their roles.

There was a room that had been identified to convert to a dedicated training room. At the time of inspection the hospital was awaiting approval for additional training resources such as interactive manikins.

Staff were appointed following the providers recruitment processes that included completion of an enhanced disclosure and barring (DBS), references checks, health declaration and registration checks if applicable. We reviewed a sample of staff employment files and found gaps in information provided. There were no details of health or immunisation status for staff and evidence provided was not consistent. We escalated this, however only training details were provided for the staff files checked.

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.

The hospital assessed and managed the risk of infection. Staff detected and controlled the risk of it spreading by following policies. Infection and prevention and control data was collected and reviewed. Where required, actions were taken to improve shortcomings.

The hospital managed infection risks well. There was a provider infection prevention and control policy that covered a range of Infection Prevention Control (IPC) policies such as hand hygiene and linen use and disposal.

We saw staff were following infection control principles including compliant handwashing and the use of personal protective equipment (PPE). Staff supported infection prevention and control measures by following the uniform policy. Nail varnish and jewellery was not worn, and staff in clinical areas had arms bare below the elbow to allow for full hand decontamination.

The hospital used systems to monitor any surgical site infections. There had been 6 wound infections reported in the 12 months prior to inspection. All suspected infections were reviewed and investigated. No themes had been identified.

The hospital had introduced a wound clinic to review any post-operative concerns.

A range of audits were completed; all with 100% compliance.

Theatres and ward areas were visibly clean, free from clutter and had suitable furnishings which were clean and well-maintained. There had been recent refurbishments in both the theatre and the ward. The theatre environment followed national guidance. Patients we spoke with commented on how clean the hospital was including their rooms.

Deep cleaning was completed with the most recent in February 2026.

IPC was part of mandatory training requirements. There was 98% compliance for level 1 and 94% for level 2.

There was a programme of infection and prevention and control audits that were overseen by a nominated IPC nurse.

The hospital performed well in local IPC audits. In the most recent audits, the scores showed compliance with infection prevention and control measures in all clinical areas. The hospital had been awarded bronze for the ANTT Patient Protection Accreditation Programme valid from May 2025 to May 2028. ANTT refers to aseptic non-touch technique.

For 50 steps cleaning audit in theatres in March 2026, compliance was 98%. Linen management compliance was 100% in February 2025 and August 2025. The ‘One together’ audit practice review was 99% compliant in February 2026.

An Environmental Cleanliness Audit using fluorescent markers had been completed showing 97% compliance.

In the Patient-Led Assessment of the Care Environment (PLACE) review in 2025 the hospital scored 100% for IPC.

Hand hygiene audits compliance was an average of 93% in 2025 and 96% in 2026.

Housekeeping achieved CAP (Continuous Advanced Programme) gold award that represented a commitment to excellent standards of hygiene in housekeeping and food service in catering.

Flooring was compliant with best practice guidance and easy to clean.

The management of clean and used surgical equipment and the flow through theatre reduced the risk of cross contamination. Staff checked the condition of sterile packs before they were opened and prior to use and surgical instrumentation was sterilised off site at another provider hospital.

There was appropriate testing of water outlets and air exchange systems in theatres. Water testing was completed monthly with ongoing monitoring with housekeepers flushing taps during routine cleaning.

Senior leaders told that due to the age of the building, work had been planned for upgrades of pipework, and this was on the risk register.

Staff understood the process for managing spillage of body fluids both on the wards and in theatres. We were given an example of an incident where a recent spillage in theatre had been managed well.

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.

The hospital had systems and processes to safely prescribe, administer, record and store medicines. There was a provider policy for medicines and Controlled Drugs (CD’s) including a range of SOP’s for staff to follow. These were checked daily on the ward and in theatres. The audits of CD’s showed between March and December compliance ranged from 98% to 100%.

Doctors reviewed each patient’s medicines on admission and provided advice to patients and carers about any changes. A pharmacist was involved in patient medicines reviews.

Medicines including intravenous fluids were stored in line with local and provider policy and reduced the risk of misuse and errors. Keys to the controlled drug cupboard were held by the nurse in charge of the ward.

There was access to medicines needed in an emergency or at short notice at night and at the weekend.

Staff monitored temperatures of fridges and the environment of where medicines were stored. Audits of compliance was an average of 91% monthly. We did observe blood strips (used rarely) that had passed their expiry date were stored in the ward fridge. We escalated this at the time and they were removed immediately.

A medicines governance audit in February 2026 was 84% compliant. Actions were identified and implemented.