Oaklands 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 people were protected from abuse and avoidable harm.

This was the first assessment for this assessment service group. This key question has been rated good. This meant people were safe and protected from avoidable harm.

The service demonstrated a strong learning culture, where people felt able to raise concerns and incidents were thoroughly investigated by managers. Individuals were kept safe, with staff effectively understanding and managing risks. Facilities and equipment were clean, well maintained, and appropriate to people’s needs, with any potential risks promptly mitigated. There were sufficient staff with the right skills, qualifications, and experience to deliver care, supported by regular training and appraisals to maintain high standards. Medicines were managed safely, and people were appropriately involved in planning any changes.

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.

All staff we spoke with told us they knew how to raise incidents and concerns and how to report them. Staff raised concerns and were encouraged to report incidents by their managers. Managers recognised this as reflective of a strong reporting culture, where staff consistently reported incidents and near misses.

Incidents were reported through an online incident management system which all staff had access to. Staff told us incidents were investigated in a timely way. Incidents were discussed within daily safety huddles, governance meetings and team meetings. Managers investigated incidents and shared lessons learned with the whole team and the wider service.

The hospital had implemented and followed the NHS England approach to reporting and investigating patient safety incidents, called the Patient Safety Incident Response Framework (PSIRF). Staff were aware of this process.

The registered manager told us that reported incidents were discussed at a patient safety incident review group (PSIRG) on a 2-weekly basis. This meeting allowed representatives from different areas of the hospital, for example theatre staff or outpatients staff, to discuss incidents holistically and see where learning was required. Anyone could attend these meetings to discuss incidents, and staff were encouraged to attend from each area.

The requirement to meet duty of candour responsibilities was also checked at these meetings. Staff understood the duty of candour and followed the provider-level policy. They were open and transparent and gave patients and families a full explanation if things went wrong. Learning was shared across all areas of the hospital through team meetings and lessons learnt templates. Learning and safety alerts were also shared with other hospitals in the group through “safety flashes”, which ensured any actions were implemented in line with national guidance.

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 is managed, monitored and assured. Staff made sure there was continuity of care, including when people move between different services.

The service provided procedures for both private fee-paying and NHS patients. NHS patients accessed the service through GP referrals. All referrals were reviewed to ensure patients met the clinical criteria for treatment and that procedures could be carried out safely. Where patients did not meet the required criteria, referrals were declined and patients were either redirected to an appropriate acute hospital, or the service contacted the referring GP to provide advice and discuss alternative care pathways.

The service had a clearly defined inclusion and exclusion criteria to support safe decision-making. Where patients presented with risk factors, their care was discussed at a complex case meeting where a multidisciplinary review took place to ensure an appropriate and informed decision was made regarding treatment. Patients were not booked for any procedures until the multidisciplinary review had been completed and it was confirmed that the procedure could be carried out safely.

The service had clear protocols in place to guide the transfer of patients to an acute hospital in the event of an emergency. These outlined the circumstances under which escalation was required and supported staff to respond promptly and effectively. The endoscopy team also had a separate, defined pathway for managing patients who experienced complications during or after a procedure, ensuring that timely assessment, intervention and escalation took place where necessary to maintain patient safety.

In line with Joint Advisory Group on Gastrointestinal Endoscopy (JAG) accreditation guidance, the staff met prior to each list to review patients and identify any potential risks or concerns. A standardised pre- and post‑procedure safety checklist was completed for each endoscopy list to promote effective communication, confirm key safety information, and support safe patient care throughout the procedure pathway.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff 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.

The service had policies in place for safeguarding adults at risk of abuse and neglect. The policies provided clear guidance to staff on how to recognise potential safeguarding concerns, take appropriate action to protect people from harm, and escalate concerns in line with local procedures. Staff were supported to follow the policy to ensure the safety, wellbeing, and protection of patients who may be at risk of abuse or neglect.

Staff received safeguarding training appropriate to their role, which enabled them to recognise and report abuse effectively. We did not receive individual endoscopy staff data on safeguarding training compliance as all endoscopy procedures were carried out by the existing theatre staff. However, mandatory training performance for this staff group showed 98% compliance for safeguarding adults levels 1, 2 and 3 and for safeguarding children levels 1 and 2, which met target compliance rates.

Staff demonstrated a clear understanding of safeguarding adults at risk and told us they followed the service’s safeguarding policies and procedures. They were able to explain how to make a safeguarding referral, understood when concerns should be escalated and knew who to inform if they had safeguarding concerns. The registered manager shared an example of how patients were given the opportunity to raise any concerns confidentially with staff in line with the provider-level safeguarding policies.

Staff knew how to access support from the designated safeguarding lead. They told us that learning from any safeguarding incidents was shared as part of daily safety huddles and meetings. Managers reviewed safeguarding incidents and identified any immediate actions where 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

At the preoperative stage, endoscopy patients had a comprehensive appointment to discuss risk factors and plan accordingly for both before and after surgery. Staff completed risk assessments for each patient on arrival using a recognised tool and reviewed this regularly, including after any incident. Patient records included risk assessments such as for venous thromboembolism (VTE), pressure damage, nutritional needs, manual handling, risk of falls and infection control risks.

The service had a policy for the use of conscious sedation. Staff ensured patients who had received sedation were given information before and after the procedure. All sedated patients required an escort to ensure someone stayed with them following their procedure, in line with national guidance.

The medical and nursing staff completed a modified ‘five steps to safer surgery’ checklist in endoscopy. This is a recognised system of checks before, during, and after surgery, designed to prevent avoidable harm and mistakes during surgical procedures. We observed staff performing the checklist correctly during our visit.

Endoscopy theatre staff carried out safety huddles prior to commencing procedures and conducted a debrief at the end of the theatre list. We looked at the records of 6 patients who had undergone endoscopy procedures and these showed World Health Organisation (WHO) safety checklists were completed correctly. These checks consisted of a team briefing, sign in (before anaesthesia), time out (before surgery starts), sign out (at the end of the procedure) and debrief.

Staff used a nationally recognised system to identify patients at risk of deterioration and escalated concerns appropriately. The National Early Warning Score (NEWS2) was used consistently to monitor patients’ physiological observations which included their heart rate, oxygen saturation and blood pressure. Staff carried out routine monitoring in line with patients’ individual clinical needs, which supported the early recognition of changes in their condition and enabled timely escalation and intervention when required.

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 endoscopy service had suitable facilities to meet the needs of patients for the type of care delivered. The day case unit consisted of a surgical admissions unit with 3 individual bays and a separate day case ward with capacity to accommodate 8 patients in individual pod bays. Each pod was single occupancy to prevent any risks of cross infection, and contained a chair, accessible call bell, oxygen suction where clinically required.

In line with JAG accreditation guidance, all areas in the endoscopy theatres and decontamination areas were well maintained and designed to support safe, efficient patient flow. The environment supported ergonomic and effective working practices for staff. Access to clinical areas was appropriately controlled to maintain patient privacy, dignity and safety.

Staff had access to suitable and well‑maintained equipment in both the endoscopy theatres and recovery area. Arrangements were in place and staff could source further specialist equipment if needed. We reviewed electrical safety testing records and found all equipment had been tested within the required timescales. Consumable items were appropriately stored and in date.

We saw daily checks of all equipment had taken place. Appropriate resuscitation equipment was available and checked accordingly in the recovery department.

Fire safety arrangements were regularly considered at health and safety meetings, and an annual fire safety audit took place, which included actions that had been documented and completed appropriately. Substances that met Control of Substances Hazardous to Health (COSHH) regulations were all stored appropriately in a locked cabinet.

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. Staff worked together well to provide safe care that met people’s individual needs.

The service had enough staff to keep patients safe and manage demand. All endoscopy procedures were carried out by staff who were fully trained for endoscopy procedures. Staffing levels were reviewed daily to ensure they met service requirements, and there was a suitable mix of full‑time staff within the department. The registered manager told us 3 other surgical staff had started completing their endoscopy competencies to ensure they were appropriately trained and competent to support endoscopy procedures.

Staff also had regular one-to-one meetings and annual performance development reviews (PDRs), which included professional development considerations.

Managers ensured that all new staff, including bank staff, received a comprehensive induction as part of established processes to support safe integration into the department and its working practices. A structured induction programme was in place, during which new starters worked in a supernumerary capacity for 2 weeks, allowing time to build competence and confidence. Induction arrangements were adapted to reflect individual needs and prior experience, and each new member of staff was allocated a buddy to provide ongoing support and supervision throughout the induction period.

The service ensured staff completed mandatory training relevant to their roles, including basic life support (BLS) and immediate life support (ILS). We received compliance data for the whole surgical service, which included endoscopy, and saw evidence that mandatory training compliance for BLS was 98% and ILS was 88%.

Overall mandatory training compliance was 90% for nursing staff in the service, which was narrowly below the providers target of 95%. The JAG training programme was in place for qualified nursing staff, which included direct observation in practice assessments, competency assessments and endoscopy ‘Endo 1 and 2’ assessments. This ensured that all staff had the appropriate qualifications, experience, skills and competencies to perform their duties and were appropriately supervised.

We scored the service as 3. The evidence showed a good standard. The service assessed and managed the risk of infection. Staff detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The environment and facilities supported safe service delivery and met relevant national standards, including JAG requirements and Health Technical Memorandum (HTM) standards for decontamination. The service also complied with HTM 01-06 guidance, ensuring appropriate ventilation arrangements were in place to reduce the risk of airborne infection.

The endoscopy suite had a decontamination room where used scopes were processed in a decontamination unit and placed in a drying cabinet following each endoscopy procedure. Scopes were tagged with barcodes throughout this procedure to ensure traceability and ensure there was maintenance of strict infection prevention and control measures. Risk assessments for single room decontamination had also been completed in line with the Institute of Healthcare Engineering and Estate Management (IHEEM) requirements and an audit held in March 2026 showed 100% compliance.

There were clear processes for clinical specimens when sent to the laboratory. Waste, including clinical and hazardous waste, was handled and disposed of safely.

Staff had access to current Infection Prevention and Control (IPC) policies and guidance, demonstrated a good understanding of IPC practices and took appropriate action to escalate concerns, when identified. Systems were in place to ensure IPC concerns were reviewed and managed every working day.

All areas we inspected, including clinical areas, waiting areas, and corridors, were visibly clean and well maintained. Alcohol‑based hand sanitiser was available at the entrance to all clinical areas. Housekeeping staff were present and active throughout the hospital. Food hygiene standards were followed when patients were offered refreshments. Staff cleaned equipment appropriately between patients and had ready access to suitable personal protective equipment (PPE).

The endoscopy service had its own IPC link nurse. The hospital had a named IPC lead who oversaw day‑to‑day arrangements across the hospital and maintained effective communication links with all departments. The IPC lead also supported training and education, working closely with the housekeeping team and departmental representatives.

The service undertook a programme of IPC audits within the department, including hand hygiene compliance, sharps management and surgical site infection monitoring. Audit outcomes were mostly positive. Where shortfalls were identified, managers had implemented clear action plans to drive improvement and monitor compliance.

Medicines were stored securely and areas used to store medicines had temperatures monitored to ensure they were kept within recommended ranges. Staff in the surgical department demonstrated full compliance with medicines management training. Controlled drugs were managed in line with legislation and there was evidence of staff doing regular checks.

There was a clinical pharmacy service available on weekdays and staff had access to an on-call pharmacist if advice was needed out of hours. Pharmacy staff proactively checked clinic lists to capture any patients who need further input about their medicines before they attended their appointment, and attended meetings related to complex patients.

Allergy statuses were documented on all records we checked. However, we found that when oxygen had been used during sedation this hadn’t always been prescribed or documented appropriately. In addition, there was no record of intravenous (IV) cannula insertion within the care pathway documentation, although there was clear and complete documentation of the removal of the cannula following the procedure.

There was a process in place to supply people with medicines to take home with them if needed after the procedure and there was access to prescription stationary if this was needed.

Pharmacy staff completed audits of prescribing and safe and secure handling of medicines and created action plans when non-compliance was found. When medicines incidents had occurred, these were reported and investigated, and clear actions were developed and shared with staff.