Oaklands Hospital

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• 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.

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 delivered care that made people feel safe, supported and involved in care decisions. Safety events were thoroughly investigated and reported, with lessons learned to embed good practices. The service collaborated with people to maintain safe care systems, ensuring continuity when moving between services and departments. Regular audits and benchmarking underscored a commitment to evidenced based practice.

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. The hospital provided incident data for outpatient services which showed 54 incidents in the 12 months prior to our assessment, with 94% of incidents classified as low or no harm. Post operative complications classified as moderate or above harm, constituted for 6%, this included thrombotic, when blood thickens and forms a clot inside a blood vessel, and wound complications. Staff told us they felt comfortable raising concerns and had access to debrief support when needed. The physiotherapy department reported 1 incident of low or no harm within the same period.

Learning from safeguarding incidents was shared through a variety of meetings and communication methods. All staff we spoke with could describe learning from incidents and how it had been shared in team meetings. Staff received feedback from the investigation of incidents, both internal and external to the service.

Managers shared learning with their staff about never events that happened elsewhere. Never events are serious patient safety incidents that should not happen if healthcare providers follow national guidance on how to prevent them. There had been no never events and no serious incidents reported in the outpatients or physiotherapy departments in the previous 12 months. However, learning from never events and serious incidents in other Ramsay hospitals were shared at staff meetings and in safety huddles.

Staff understood the duty of candour. They were open and transparent and gave patients and families a full explanation if things went wrong. Staff gave examples of when they had fulfilled the duty of candour. One related to a miscommunication in a patient’s appointment time. Staff ensured the patient received an appointment soon after with minimal delay and worked with colleagues to identify the cause of the problem.

We reviewed evidence of an incident which led to improved care and treatment. It related to a sample misplaced during an outpatient appointment. Appropriate actions had been put in place and learning had been shared. One staff member told us, “there is a learning culture here, not a blame culture… we all want to do our best for each other and the patients.”

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.

The service’s booking processes ensured that enough information was provided in advance to assess whether patient need could be safely met. Staff had access to patients’ clinical histories before appointments, supporting safe triage.

Risk assessments were carried out prior to appointments and treatment, with information shared appropriately with care teams. Staff knew about and dealt with any specific risk issues, for example, staff worked with colleagues internally to deal with risks such as deteriorating conditions and safeguarding concerns.

Reception staff made initial patient checks such as personal details and chaperone requests on the patient’s arrival at the department. The outpatient department (OPD) was open 8am to 8pm Monday to Friday and 8am to 4pm Saturday, there was medical cover throughout this time. The service provided procedures for both private fee-paying and NHS patients. NHS patients were referred from the patient’s GP. Services were designed to meet the needs of the population, and we saw evidence that all patients were seen within 18 weeks of referral to the hospital.

Private fee-paying patients could also self-refer. Information on how to self-refer for treatment was available on the hospital website and within the OPD, which also included methods of payments for various procedures.

We saw evidence that the service had defined inclusion and exclusion criteria. Patients with identified risk factors were discussed at a case meeting to inform a final decision. Risk factors included conditions such as elevated blood pressure and cardiovascular or renal complications.

We observed a patient's journey from initial check in with the outpatient team to their post operative recovery physiotherapy appointment. We saw appropriate checks and handovers between teams. We checked electronic patient records and found these to be correct and up to date. Staff told us that outpatients preparing for surgery were always asked about their consent and offered guidance about any procedures.

The patient's welfare was checked regularly during appointments and staff arranged follow up appointments.

We scored the service as 2. The evidence showed some shortfalls. While the service had suitable safeguarding policies and procedures that aligned with the needs of their patients, the service could not demonstrate sufficient compliance with safeguarding training.

There was a designated safeguarding lead trained to level 3 adult safeguarding, 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.

Safeguarding concerns were recorded and referred appropriately, with oversight maintained through regular governance meetings.

Staff told us how they would escalate safeguarding concerns and knew how to identify adults and children at risk of, or suffering, harm. This included working in partnership with other agencies. Staff gave examples and we saw examples of staff taking appropriate action to reduce the risk of ongoing harm to patients and their families. This included investigation and cooperation with safeguarding partners. However, at the time of our assessment, the hospital provided data showing that only 16% of staff within the OPD had up to date, face to face safeguarding training relevant to their roles with a hospital target of 85%. This was raised with the managers who explained that staff members had been booked onto training courses but had not yet attended due to trainer sickness and external factors out of their control.

Staff followed safe procedures for any children visiting the OPD and assessed this on an individual basis.

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 service had guidance in place to support staff in discussing the benefits and risks of treatments with patients before procedures 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.

Staff had clear guidance to follow should a patient’s condition deteriorate while they were in the OPD. We saw evidence the outpatient team had scored 100% in a simulated emergency exercise in February 2026.

Patients told us staff explained things well, and the risks and benefits or any treatment were discussed. They said they felt confident they could ask further questions and make informed decisions.

We reviewed 5 sets of patient records and found all required information was present, including risk assessments and signed consent forms where appropriate.

Staff used nationally recognised tools to improve the detection and response to clinical deterioration in patients. We saw evidence that 100% of all OPD staff were trained in basic life support (BLS) with 100% of nurses and doctors trained in immediate life support (ILS).

There were clear care pathways in place so that treatment was appropriate, timely and effective.

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.

All of the areas visited in the OPD during our assessment were clean, well maintained and free from clutter. However, during a routine check of the corridor, an unattended dressings trolley was observed. The trolley contained unsecured sharps that included scalpel blades, scissors and syringe needles. The trolley was not under direct supervision and was accessible in a public corridor area which posed a potential risk to patient and staff safety. Immediate action was taken by the provider when this was raised during our assessment and all sharps were removed.

The physiotherapy department was located in a separate building next to the main hospital and was located on the ground floor. The service had enough suitable equipment to help them to safely care for patients and incorporated 4 consultation rooms and a clinical area divided into 2 patient areas. There was also an onsite gym.

The waiting areas in the departments had refreshments and reading materials available.

Staff were aware of the appropriate equipment needed for each consultation and checked the availability of these before each appointment. The staff we spoke with told us that they had adequate and appropriate equipment in the department to carry out the treatments.

The OPD shared a resuscitation trolley with the radiology department. The emergency resuscitation trolley was in clear sight of staff in the middle of the department. 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.

All staff working within the OPD had completed their mandatory face to face fire safety training at the time of our assessment. The service had completed a fire risk assessment on 3 October 2025 with 2 actions completed and 1 outstanding action on going regarding the lifts moving to the ground floor on activation of the alarm. We saw evidence that the annual fire extinguisher service was completed in February 2026.

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

All new members of staff and volunteers underwent a structured and comprehensive induction training programme appropriate to their role.

There were 10 registered nurses and 4 healthcare assistants employed within the OPD. Staff told us they were flexible and able to cover shifts easily.

The physiotherapy service had enough staff to keep patients safe. The service had 1 non-clinical vacancy at the time of the assessment. There was a physiotherapy manager; physiotherapy team leader; 1 senior physiotherapist; 5 physiotherapists and 1 physiotherapy assistant.

There was a low reliance on agency staff, and continuity of care was maintained across services. Staff from the OPD could work additional shifts if required.

Staff we spoke with agreed that the staffing model in place was appropriate. We observed there were sufficient numbers of staff deployed to maintain patient safety, and patients told us they felt safe within the service. Staff working in the OPD told us that staffing levels enabled them to provide good patient care. During our observations, staff were visible across all areas and did not appear rushed.

Staff told us that any staff shortages could be immediately escalated to a member of the executive team or duty manager. In the last 12 months there had not been any incidents relating to staffing reported for the OPD.

Staff received mandatory training. The mandatory training was comprehensive with staff able to request additional or new training to ensure they could meet patient needs. However, at the time of our assessment, we found staff within the OPD were 61% compliant against a hospital target of 85%, this was raised with the OPD manager during inspection who advised that staff with outstanding training had been booked onto upcoming courses.

Updated data was received after the assessment showing OPD was 69% compliant with mandatory training. Staff told us managers monitored all training and alerted them when they needed to be updated.

At the time of our assessment the OPD had no vacancies and the department was fully staffed. The hospital had overall staff sickness rates of 5%. The service had robust performance management processes to use if staff performance issues arose. This was a centralised process with support from a dedicated human resources team.

Staff at all levels told us they received regular meaningful performance development reviews (PDRs) which provided them with development and career opportunities and their wellbeing and safety was supported. Completion rates for PDRs were 85% at the time of our assessment, with continued action from the OPD manager and head of clinical services to ensure full completion across all staff.

Staff had regular access to clinical supervision, reflective practice, and wellbeing check-ins. Staff appraisals included conversations about career development and how it could be supported. Staff we spoke told us their appraisals were beneficial to their development.

We spoke with 5 patients who told us there always appeared to be enough staff to provide good care. One patient told us, “they are never too busy if I have a question...”

Consultants completed mandatory training with their substantive NHS employer and provided annual confirmation of completion of this training to the hospital in line with the practising privileges policy. We saw evidence of this in staff files.

We scored the service as 3. The evidence showed a good standard. The service detected, assessed and controlled the risk of infection appropriately.

The environment was visibly clean and well maintained, with cleaning schedules in place and monitored.

There were hand sanitisers 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.

Cleaning records were up-to-date and demonstrated that OPD areas were cleaned regularly. All public areas had cleaning schedules. We looked at a sample of 3 checklists and found them to be up to date. We observed staff cleaning patient facing areas during our assessment.

Staff completed hand hygiene audits each month. The compliance rate was 100% for all elements in March 2026.

Staff followed infection control procedures (IPC) aligned with best practice, including protocols for room cleaning between appointments. IPC mandatory training compliance for the OPD was 76% and the latest ’50 steps cleaning’ audit from March 2026 demonstrated 95% compliance with relevant infection control protocols.

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 happen.

Staff followed systems and processes when administering and recording medicines. Medicines in the OPD were stored in locked cupboards or fridges and there were no controlled drugs (CDs) administered in the department. There had been 1 incident recorded in the last 6 months regarding medicines, this related to a missing unsigned prescription. We saw evidence that appropriate action and learning had taken place with improved processes implemented.

Fridge and room temperatures were monitored and pharmacy staff regularly refilled medicines.

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 implemented enhanced controls surrounding the storage and management of prescription pads. Previously stored in a high-traffic cupboard, prescription pads were relocated and held securely, with access restricted to the nurse in charge. The key was retained on the ward, and a formalised key-tracking system was introduced to ensure appropriate accountability. Regular audits were undertaken by the Pharmacy Technician to ensure safe and secure handling, alongside ongoing monitoring and recording of prescription pad usage.

Following an audit, further action was taken to strengthen the security of outpatient medicines cupboards. The access system was upgraded from key-based entry to keypad-controlled locks. This change was implemented in response to identified risks associated with cupboards being left unsecured when reliant on manual key access.

Medicines management training was reviewed and plans were developed to expand the programme to include specific guidance relevant to radiology and outpatient clinical areas, ensuring staff were equipped with appropriate, context-specific knowledge to support safe practice.

In addition, the Pharmacy Technician contributed to wider organisational learning through the delivery of a corporate-level presentation on the use of a practical tool for identifying patients at risk of falls. This work supported multidisciplinary collaboration, particularly with physiotherapy colleagues, and promoted improved assessment and management of patients identified as being at increased risk.

A recent ‘safe and secure’ medication audit showed 97% compliance.