Fulwood 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

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. 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.

The service had a proactive and positive culture of safety, based on openness and honesty. Safe systems were embedded across outpatient pathways. The service worked with people to understand and manage risks by thinking holistically. They made sure equipment, facilities and technology supported the delivery of safe care. The service had enough staff to provide care that met people’s individual needs. The service assessed and managed the risk of infection. The service made sure that medicines and treatments were safe.

However, the service did not consistently ensure that consultants with practising privileges were up to date with mandatory safeguarding training requirements. This included safeguarding and life support training.

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 were trained in incident reporting and understood what needed to be escalated and reported. Staff told us they felt comfortable raising concerns and had access to debrief support when needed.

The outpatient manager monitored incidents and told us that 87 incidents had been reported within the outpatient department during the previous 12 months. The most commonly reported incidents related to surgical site and wound infections, including cases identified following wound swab results, and incidents involving deep vein thrombosis (DVT).

Infection-related incidents were reviewed through Infection Prevention and Control (IPC) meetings, where trends and surgical site infection rates were monitored and discussed. Where concerns were identified, investigations were undertaken to establish any contributing factors, including a review of surgical techniques, preparation procedures and outcomes associated with individual consultants.

Staff described how increased infection rates had been subject to detailed review. Analysis found this was associated with a higher volume of procedures being undertaken, and no specific concerns were identified.

All staff we spoke with could describe learning from incidents and how it had been shared in team meetings. We reviewed outpatient department meeting minutes from December 2025 and March 2026, which demonstrated that clinical incidents were routinely reviewed and discussed.

Staff told us they received feedback from the investigation of incidents, both internal and external to the service. We observed a multi-disciplinary team (MDT) daily huddle that showed the number of incidents across the hospital was discussed.

Incidents were investigated using the patient safety incident response framework (PSIRF) in line with best practice. The patient safety incident response group (PSIRG) reviewed incidents to determine the appropriate level of response, including the need for formal investigation, and maintained oversight of themes and trends. PSIRG updates were then shared at the hospital wide clinical governance meetings for further oversight and monitoring.

Staff understood the duty of candour. They were open and transparent and gave patients and families a full explanation if things went wrong. Staff we spoke with gave examples of when they had fulfilled the duty of candour.

We reviewed 3 incident investigations which had been investigated thoroughly. We saw evidence that the service had taken action to strengthen practice and oversight following incidents. For example, development of a local standard operating procedure, clarification of referral pathways, and the completion of audits with feedback provided to staff. Learning was also shared through team meetings and ward‑based training was implemented to support improvement and prevent recurrence.

The service had also taken actions in response to incidents related to cancellations on the day. This included improvements to the pre-operative assessment process such as changes to the way patients were marked as ‘fit to proceed’ and a new ‘follow-up’ process had been implemented.

The service shared information about complaints with staff through a complaints bulletin, which included a summary of complaints, outcomes and key themes. Complaints were also discussed in heads of department meetings and the medical advisory committee (MAC).

Training data showed that all outpatient and physiotherapy staff had completed ‘speak up for safety’ training.

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.

Safe systems were embedded across outpatient pathways and appointments were delivered under consultant or an appropriately qualified clinician.

Patient records we reviewed contained clear documentation of patients' presenting concerns, assessments, treatment provided, outcomes and any required follow-up actions. Staff verified patient identity, referral information, funding arrangements, and clinical need prior to attendance to ensure safe and appropriate care delivery.

Patients requiring follow-up appointments were either booked before leaving the department or contacted by the bookings team to arrange a future appointment.

The service followed corporate policies and procedures that guided staff through the patient journey from referral to discharge. Policies we reviewed were comprehensive, in date and in line with national guidance. This included a patient journey policy and standard operating procedures for admission and discharge. The discharge process included checklists to confirm that patients were medically fit for discharge, and that appropriate outpatient or physiotherapy follow-up appointments were booked where required.

The service had an outpatient initial consultation appointment policy and standard operating procedures were in place for patient-initiated follow-up that aligned with NHS guidance.

A standard operating procedure was also available for staff to follow to support the emergency transfer of critically ill patients to local NHS critical care units when their needs exceeded the level of care available on site.

Patients referred for an outpatient consultation were sent an appointment letter and a patient health questionnaire to complete in advance. This supported early clinical assessment and the preoperative process, and enabled clinicians to assess suitability for treatment or surgery at the initial appointment.

Staff attended outpatient daily huddles to review staffing, the number of clinics running, emerging concerns, and feedback including compliments and complaints.

The outpatient service followed a schedule to complete regular audits to support safe systems of care and review practice against standards, including National Safety Standards for Invasive Procedures (NatSSIPS).

Data provided from the patient medical records audit showed improved compliance from 73.4% (February 2025) to 100% (February 2026). The audit results noted that all records included a comprehensive initial consultation note, signed operation notes, and written post-operative instructions. Every patient had received a post-discharge follow-up call or documentation, and post-op appointments were scheduled before discharge.

We saw evidence that the service had an inclusion and exclusion criteria. Risk factors included cardiovascular, respiratory and neurological co-morbidities.

The outpatient department had a process in place for managing missed telephone calls. The department received 563 calls in January, 442 in February and 453 in March, with an average missed call rate of 19%. Staff told us that unanswered calls were automatically diverted to a voicemail system. Administrative staff and registered nurses routinely reviewed voicemail messages and returned calls as required, ensuring patients received a timely response and that any queries, appointment requests or concerns were appropriately followed up.

We scored the service as 2. The evidence showed some shortfalls. The service could not consistently evidence that all consultants with practising privileges had submitted current evidence of mandatory safeguarding training requirements. However, the service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that.

Consultants who held practising privileges at the hospital were required to complete safeguarding training at their substantive posts within NHS hospitals. The hospital target for mandatory training was 95%. However, safeguarding training compliance for consultants with practising privileges was significantly below the hospital target (95%), at 51.9% for safeguarding children level 1 and 2 and 51.9% for safeguarding adults level 1 and 2.

The service followed a corporate training matrix which clearly outlined the appropriate level of safeguarding training required for each role. The training matrix and adult safeguarding policy outlined the requirement that a level 3 trained senior registered practitioner must be available on every shift.

Current training compliance for safeguarding training showed that this requirement could be met. Staff compliance for the outpatient service, including physiotherapy for safeguarding adults level 3 was 100%. Compliance was also 100% for both adult and children’s safeguarding training level 1 and 2. The safeguarding lead had completed level 4 training.

The service followed corporate safeguarding policies on how to identify and report any safeguarding concerns. Policies we reviewed were comprehensive, in date and had been updated in line with national guidance. Staff we spoke with were aware of the provider’s safeguarding policies.

We reviewed clinical governance meeting minutes, which showed that safeguarding was a standing agenda item. Safeguarding training updates and incidents were routinely discussed at these meetings to ensure ongoing oversight and monitoring.

There was a designated safeguarding lead who staff could contact for advice and escalation. Staff we spoke with told us that the safeguarding team were easily accessible if required and could give examples when they had contacted them for advice and what the outcomes were.

Staff demonstrated a good understanding of safeguarding processes and escalation routes. They told us they would raise concerns with senior nurses, managers or safeguarding leads if required. Staff explained that they would ensure patients were able to speak privately if sensitive safeguarding concerns were identified.

We saw examples of when staff in the outpatient service had escalated safeguarding concerns to the safeguarding lead and had taken appropriate action to reduce the risk of ongoing harm to patients and their families.

Safeguarding grab packs had recently been provided to all departments to help staff quickly access important information and support when needed.

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.

The service worked with people to understand and manage risks by providing care in a way that was safe and supportive and enabled them to do the things that matter to them.

The hospital had an exclusion criteria to ensure that they cared for patients whose risks they could manage. The preoperative assessment covered both physical and psychological needs of patient prior to admission.

Staff explained the referral process and described how referrals received through the electronic referral system (eRS) were transferred onto the hospital's electronic patient management system for triage. Referrals were reviewed against agreed acceptance criteria, with clinical advice sought from outpatient nurses when required. Examples of exclusion criteria included patients with a body mass index (BMI) above 40 or clinical conditions that could not be safely managed within the service. Staff told us referrals that could not be accepted were returned through the system, allowing referrers to seek alternative providers.

The service had guidance in place to ensure staff discussed the benefits and risks of treatments with patients before procedures. Staff told us they discussed the risks with patients at initial appointments in the OPD, and these were mentioned again when obtaining patients' consent. Staff told us patients were offered the chance to ask questions or raise concerns at all stages of their patient journey.

We reviewed 5 patient records. Records demonstrated that patients were involved in managing risks associated with their care and treatment through informed discussions and shared decision-making. Records included completed medical questionnaires, details of clinical assessments, discussions regarding treatment options and arrangements for follow-up care. Patients listed for surgery had documented height, weight and BMI measurements, and signed consent forms were present where required.

Clinical notes demonstrated that consultants discussed symptoms, reviewed relevant diagnostic investigations, completed examinations and used chaperones where appropriate. Records showed that patients were provided with information about the risks, benefits and expected outcomes of treatment, including surgical options, and were supported to make informed decisions about their care. Follow-up arrangements were clearly documented and included referrals to physiotherapy, routine review appointments and patient-initiated follow-up pathways where appropriate.

Staff shared examples of how they had involved patients in recognising and managing risks. They described how a physiotherapist had identified potential undetected health concerns and supported the patient to seek further assessment. This had supported a timely diagnosis and had reduced the risk of harm for the patient.

We scored the service as 3. The evidence showed an overall 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 outpatient department consisted of a range of clinic rooms, including dedicated ophthalmology and gynaecology facilities, a dressing clinic and pre-operative assessment areas.

Most consultation rooms were equipped with examination couches, curtains and computer facilities. There was also a larger room primarily used for gynaecology appointments. A dedicated dressing room was available for patients requiring suture removal, wound assessments and the management of post-operative complications.

The ophthalmology service operated from a dedicated room equipped with specialist ophthalmology equipment.

A minor operations room was available; however, surgical procedures requiring specific ventilation standards were not being undertaken at the time of our assessment due to airflow levels not meeting the required specification. Staff told us engineering teams were reviewing options to address this issue. The room continued to be used for non-surgical procedures such as dressing changes and coil fittings.

All the areas visited in the outpatient department during our assessment were clean, well maintained and free from clutter. A storeroom was being refurbished to improve stock organisation and support infection prevention and control requirements. Stock levels were monitored by the pre-operative assessment team, and the store manager completed annual stock checks to ensure adequate supplies were available.

The staff we spoke with told us that they had adequate and appropriate equipment in the department to carry out the treatments.

Staff described robust arrangements for managing equipment and medical devices. Equipment servicing and repairs were managed through an external provider and staff submitted requests through an electronic reporting portal when faults were identified.

The service maintained oversight of equipment through attendance at regular medical devices committees. Equipment that was overdue for servicing or required repair was removed from use until deemed safe. A healthcare assistant from the pre-operative assessment team accessed and maintained equipment monitoring records and attended committee meetings alongside the outpatient manager. The meetings also considered medical device safety alerts, policy updates, incidents involving medical equipment, maintenance and repair issues.

Staff maintained training folders and service manuals for equipment and provided regular updates to senior managers regarding equipment compliance and maintenance.

We reviewed clinical governance meeting minutes, which demonstrated that equipment and environment were regularly discussed to ensure appropriate oversight. Minutes from January 2026 showed that managers were required to provide assurance reports on medical devices, confirming they were serviced and in date, with clear plans in place for those that required servicing.

There were hand sanitizers at the entrance and throughout the department. We observed staff decontaminate their hands on entry and exit to consultation rooms as well as before and after any patient interactions.

There was access to personal protective equipment (PPE) such as gloves and aprons in all consultation rooms.

Sharps containers were clearly labelled with the date and the name of the staff member assembling, locking and disposing of them. Bins to accommodate different types of waste were clearly identified, enabling safe disposal by staff.

We reviewed Legionella monitoring documentation and found records were completed consistently, indicating that regular water temperature and safety checks were undertaken to reduce the risk of Legionella infection.

The department had a resuscitation trolley, and we observed that the contents were secured with a tag. We saw evidence that daily checks took place on the resuscitation trolleys to ensure the seal had not been broken. Logbooks showed staff had signed to indicate the resuscitation equipment had been checked and was safe and ready for use in an emergency. A further checklist was used to identify disposable items due to expire the following month. These were disposed of and replaced. Single-use items were sealed and in date. Checks of all contents in the resuscitation trolleys took place monthly.

We scored the service as 2. The evidence showed some shortfalls. The service had enough staff to provide care that met people’s individual needs. However, the service could not consistently evidence that all consultants with practising privileges had submitted current evidence of mandatory training requirements.

The service followed a corporate mandatory training policy that was comprehensive and in date. The policy had been updated when necessary to align with changes to legislation and best practice.

The outpatient department had 79 consultants who worked under the terms of the hospital’s practising privileges policy. The service had processes in place to check consultants met the terms of this policy and monitored relevant training.

Consultants with practising privileges were required to complete mandatory training through their substantive NHS roles rather than within the outpatient department. Managers monitored compliance with mandatory training against a target of 95%. We reviewed the training data and found that mandatory training compliance for consultants who held practising privileges at the hospital was low (46.49%) and 45.57% for life support training. This included basic life support (BLS), immediate life support (ILS) and advanced life support training (ALS).

This meant the service could not be assured that all consultants were up to date with mandatory training requirements, as evidence of completion had not been consistently obtained.

Overall compliance with mandatory training for outpatient staff (including nursing, healthcare support and admin) met the hospital target of 95%. This included in person training and e-learning modules such as fire safety, IPC and incidents.

Compliance for physiotherapy staff was 83.3%. This was due to one staff member whose mandatory training had expired, and they were scheduled to complete the required training.

Compliance for outpatient bank staff was 73%. Leaders told us that compliance was currently low due to reduced activity and staff usage. A focused plan was in place to improve this as demand increased.

Although training compliance was monitored, inconsistencies were identified across life support training datasets for outpatient staff. For example, BLS compliance was recorded as 88% in one dataset and 86% in another. Similarly, ILS training compliance was reported as 100% in one data submission and 89% in another.

Compliance for physiotherapy staff was consistently recorded as 100% for both BLS and ILS

Staff were allocated training that was appropriate and relevant to their roles. This was guided by a training matrix which clearly defined mandatory learning requirements and frequency across different staff groups.

Staff also completed competency training specific to their role such as wound care, observation and cannulation. Training data showed that registered nurses, healthcare assistants, and physiotherapists were 100% compliant with their allocated training

The service used a safer staffing tool within the outpatient department and adapted it to meet specific service needs. This meant that staffing levels could be maintained within the agreed safe limits to support the safe delivery of care

There were 6 registered nurses and 3 healthcare assistants employed within the outpatient department. Staff operated a flexible cross-working model between the outpatient department and pre-operative assessment service. Registered nurses, healthcare assistants and administrative staff worked across both departments to maintain service continuity and broaden their skills and experience.

At the time of our assessment, there were 2 registered nurse vacancies and 1 part-time healthcare assistant vacancy within the service. Staff told us these vacancies had not adversely affected service delivery due to effective cross-cover arrangements between departments. The service was not using agency staff and relied on substantive and bank staff familiar with the service.

The physiotherapy team included physiotherapists, team leaders, a physiotherapy technician and bank staff working across 3 provider hospitals. Clinical leadership was provided by a service lead who had oversight of physiotherapy services across the 3 locations. Staff worked across inpatient, outpatient and pre-operative services. The manager described how staff rotated between wards and outpatient clinics and could flex to support service demands.

Staff turnover within the outpatient department was low (rolling turnover rate of 0.64%). However, sickness absence was high, with a rate of 13%.

Staff told us they received annual appraisals that supported their wellbeing and provided opportunities for development and career progression. At the time of our assessment 100% of outpatient staff had completed their yearly appraisal.

Of the 79 consultants working in the outpatient department with practising privileges; 92.4% had completed annual appraisals, with the remaining 6 appraisals due to be updated and recorded.

A healthcare assistant described a structured induction and competency assessment process. Training included blood sampling, electrocardiograms (ECGs) and wound swabbing. They explained they completed practical training using simulation equipment and received supervised practice before being signed off as competent by senior clinical staff.

Staff said they felt fully equipped to undertake their role following completion of training and competency assessments.

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.

There was an infection prevention and control (IPC) service level agreement in place between housekeeping and the outpatient department. This provided clear guidance on daily cleaning tasks in each area including consultation rooms, corridor and ophthalmology. Weekly tasks and monthly tasks were also outlined such as when to undertake deep cleaning and 6 monthly changing of disposable curtains.

During our assessment we found that the environment was visibly clean and well maintained, with cleaning schedules in place and monitored. Cleaning records were visible to patients and staff and displayed on the back of consultation room doors.

Disposable curtains had been changed in line with guidance. Cleaning checklists we reviewed were up to date and we observed staff cleaning patient facing areas during our assessment.

Data from a deep clean and quality audit (March 2026) showed the service scored highly with 97% in the preoperative areas.

The most recent ’50 steps cleaning’ audit from April 2026 for the outpatient department was 93% and had improved from 78% in December 2025.

Staff completed training in infection prevention and control (IPC), hand hygiene and Aseptic Non-Touch Technique (ANTT). Compliance was 100% for outpatient staff and 75% for physiotherapy staff. This was due to one staff member whose mandatory training had expired, and they were scheduled to complete the required training.

The outpatient department manager attended monthly infection prevention link practitioners’ group meetings. Agenda items included IPC and environmental audit results and IPC standards across departments. This meant the service could review performance, identify areas for improvement and share learning.

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 followed systems and processes for administering and recording medicines. They had access to the medicines management policy which provide guidance on how to manage medicines safely and in line with local procedures.

Medicines in the outpatient department were stored in locked cupboards or fridges and there were no controlled drugs administered.

Staff could access onsite pharmacy support including a pharmacist and pharmacy technician. Pharmacy support was available throughout the week, with a pharmacy technician based on site each weekday and pharmacists working across multiple provider hospitals. Pharmacists rotated between sites and were available remotely when not physically present. Pharmacy cover was provided Monday to Friday, with on-call arrangements in place during evenings and weekends. Staff explained that pharmacists could be contacted for advice out of hours and could attend the hospital if required.

Pharmacy support included stock management, prescription checking, medicines information, audits, and training. Audit data showed that the prescribing, supply and administration of medicines audit achieved 83.9% compliance in March 2026 and had generally remained above target during the previous year. The outpatient department's medicines storage and security audit achieved 94% compliance during 2025 and 100% compliance in February 2026. Medicines governance audit compliance improved from 57% in July 2025 to 88% in February 2026.

Fridge temperature monitoring compliance improved significantly from 44% in June 2025 to 98% in December 2025, reaching 100% in January 2026 and 99% in February 2026.

Staff told us action plans were developed and monitored following audit activity to support continuous improvement.

Staff described effective systems for managing medicines and supporting patient safety. Patient medication alerts were recorded and reviewed to ensure pharmacy staff were aware of any specific medication requirements or risks. Staff said clinical teams frequently contacted pharmacy for advice and medication-related queries.

Pharmacy staff attended bed management meetings and reviewed an action tracker for patients due to be admitted within the following two weeks. These meetings identified patients with complex medication requirements who may benefit from multidisciplinary review or additional pharmacy input prior to admission.

During the period December 2024 to November 2025, there were 28 medications incidents reported across the hospital. This was a rate of 0.26% and the hospital was not an outlier for medications incidents when benchmarked with the other provider hospitals.

Staff reviewed patients' medicines regularly at appointments and provided specific advice to patients and carers about their medication. We saw evidence of this in patient records and when speaking with the clinical team.

The pharmacy team maintained a medicines management training tracker to monitor staff compliance with training requirements. Staff showed us competency-based medicines training programmes, which included detailed learning materials, knowledge assessments and competency sign-off processes.

Training covered medicines optimisation and medicines management practices. Staff completed written assessments and competency checks before being signed off as competent. Pharmacy staff monitored compliance and arranged training for individuals when refreshers were due.

Medicines management training data showed that the most recent compliance was 95.5% for outpatient staff.

The outpatient department was represented at regular medicines management committee meetings. We reviewed meeting minutes from February 2026, which demonstrated that medicines management risks, medication incidents, audit results and areas requiring improvement were routinely reviewed and monitored.

The service had taken action to improve communication about medication side effects. This was in response to patient feedback from Private Healthcare Information Network (PHIN). Pharmacy staff had enhanced patient education and discussed medication side effects during both pre-operative and post-operative visits. This had led to improved patient experience, and the relevant PHIN score had improved and remained at 9/10 or above from June 2025 onwards.