Rivers 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 under our new methodology 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.

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. Learning from incidents was used to identify and embed good practice.
 

Staff understood when and how to report incidents. They were supported by leaders to escalate concerns and leaders were prompt to act. Learning was shared with clinical, administrative and non-clinical teams by emails, newsletters and daily meetings. This ensured all staff groups were included and understood how learning applied to their roles. Staff were supported following incidents with debriefs and psychological support if needed. 
 

Surgery team leaders held daily huddles with their teams to share new clinical instructions and information regarding patient lists. Monthly department meetings were also held to discuss safety alerts, learning from incidents and performance. This included sharing safety alerts across all Ramsay locations and updating staff on the top 3 risks for the Rivers location. Staff were required to sign acknowledgement of any safety updates. Theatre staff also had a designated clinical update room where notice boards were updated daily, and information on project leads was accessible to staff. 
 

Staff knew the importance of being open and honest when things went wrong. Leaders supported staff during investigation processes. Identified learning and recommendations were shared throughout the Ramsay Health Care UK group. For example, surgery implemented a new falls prevention scheme following an increase in inpatient falls. This was shared across all Ramsay locations. 
 

The service had a ‘Being Open’ policy which included guidance on duty of candour for staff and leaders. Duty of candour means, providers must make sure those providing care are open and transparent with the people using their services, whether or not something has gone wrong. The policy was in date and accessible to staff. We reviewed 3 duty of candour letters which had been completed within policy timeframes. The letters were open and transparent, shared investigation findings and gave apologies to patients in line with regulations. 
 

Incidents and concerns were investigated in line with the services policy. Surgery had reported 183 incidents from October 2025 to April 2026. Of these, 35 remained open at time of our assessment. There were 0 never events in the 12 months prior to our assessment. A never event is a serious, largely preventable patient safety incident that should not occur if healthcare providers have implemented existing national guidance or safety recommendations. 
 

When necessary, incidents were reported through notifications to external bodies such as the Private Healthcare Information Network (PHIN). Incident themes and investigation outcomes were discussed at the quarterly services Medical Advisory Committee (MAC) attended by the service’s senior leadership teams. 
 

Leaders promoted a positive proactive approach to learning from incidents and complaints, taking a multidisciplinary approach to services improvements. Patients and staff were kept updated during investigation processes and included in discussions about outcomes and service improvements.
 

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.
 

Patients we spoke with understood the referral, booking and pre-admission processes. They were provided with clear information and instructions from staff throughout their care journey. Privately funded and National Health Service (NHS) patients received the same surgery care pathway. On the day of surgery, patients were supported and informed of all stages of their care. They told us there had been excellent continuity of care and felt supported by all staff. 
 

The service had a pre-admission unit where staff undertook pre-operative checks. This included clinical observations, completion of risk assessments and consent forms. Audits for pre-admission processes showed good compliance. Patients were supported by staff to understand their surgical procedures and staff would seek support from interpreter services if required. Patients were encouraged to include family and carers in decision making. 
 

Staff followed robust surgery acceptance criterion for all patients. Those with complex medical conditions that required additional clinical interventions during surgery were discussed with medical teams prior to surgery. Patients deemed too high risk would be referred to general practitioners (GPs) or their NHS provider. There were no intensive care facilities at this location. 
 

Staff followed the World Health Organization (WHO) surgical safety checklist prior to and post-surgery for each patient. Training and effective governance systems ensured 100% compliance with this national guidance for patient safety. 
 

Staff followed clear processes for transferring patients from theatres to recovery then onto the ward. Checks carried out throughout this journey were recorded in each patient’s notes. Patients were kept informed throughout this transition and we observed staff giving patients reassurance as they recovered from their anaesthetic. They were only transferred onto the ward once safe to do so. Staff knew the processes to follow if a patient deteriorated in their care. The service had procedures in place to support staff decision making in an emergency that enabled safe patient care. 
 

Leaders focused on clear patient centered care pathways. Governance and risk management processes were in place to monitor pre-admission, admission and discharge processes. Guidance was provided to support staff to deliver continuity in care. For example, staff followed processes that enabled safe effective discharge following surgery that included follow-up appointments, physiotherapy support and sharing discharge summaries with GPs or NHS providers. 
 

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. 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.
 

Patients we spoke with felt supported by staff and able to raise any concerns to those caring for them.
Most staff were trained at the appropriate safeguarding level for their role. Staff understood safeguarding well, were clear on their responsibilities and were confident in recognising and reporting signs of harm or risk of harm. The service had a safeguarding policy that was in date and accessible to staff.
 

Following our assessment evidence provided showed that safeguarding training compliance for levels from 1 to 3 for adults and children showed varied compliance rates Surgery bank staff compliance for safeguarding training was below the target of 85% with 55% of staff overdue training; however, leaders had an action plan with timescales to improve compliance. Staff working with children undertook safeguarding supervision in line with the services policy.
 

Surgery safeguarding leads were level 3 trained and responsible for staff training, oversight and monitoring of safeguarding processes. They were supported within their roles by senior leadership through monthly meetings. Leads worked with system partners and local authorities to support timely referrals and shared learning. Examples of recent safeguarding referrals were shared that showed timely actions taken and clear documentation by staff. External partners had been informed, and relevant agencies had been made aware of safeguarding concerns. 
 

Staff had received training that was supported by the service’s policies for assessing patient’s mental capacity and human rights. Staff ensured patients received appropriate support, for example where they required interpreters or a chaperone. 
 

Leaders ensured the safeguarding systems were embedded within day to day practice. Staff were supported to raise concerns and escalate to the appropriate agencies and received feedback from referrals. 
 

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.
 

Patients were included in all decisions about their surgery. All associated risks regarding anaesthetic, surgery procedures and complications were discussed with patients prior to their surgery. Patients with specific medical conditions such as diabetes were flagged prior to admission so that teams were aware. 
 

Consent forms were completed at multiple stages of the surgery pathway. With a final consent completed by the surgeon carrying out the surgery. We saw good communication between clinicians and patients. Risks and potential complications were discussed to enable patients to make informed decisions.
 

Surgery risk assessments were completed by staff pre and post operatively. We reviewed 5 patient records and all initial relevant risk assessments had been completed; however, it was not always clear if these assessments had been updated following a prolonged stay on the inpatient ward. Leaders had identified this as an area of improvement and had taken action to address compliance.
 

Staff we spoke with told us they were supported to escalate any patient concerns. For example, staff had acted quickly when a patient’s blood pressure was high and escalated this to the Resident Medical Officer (RMO) for review. 
 

Staff had received training on the recognition of deteriorating patients and had access to a pocket guide to support clinical decision making. This included process flows for pain and sepsis management that used nationally recognised tools like National Early Warning Score (NEWS).

Leaders monitored patient care records for evidence of appropriate escalation of patients through audits. Evidence showed improved compliance month on month showing good compliance of 92% at time of assessment. 
 

The service had policies and procedures in place to support the management and escalation of risk. An RMO was available 24 hours a day for onsite medical support. Leaders ensured staff worked effectively across teams throughout the patients care journey. 
 

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.
 

Patients across all areas of surgery felt the environment was safe and met their needs. Patients told us call bells were responded to quickly by staff and had equipment available such as walking aids and grab rails should they need them. 
 

Access to areas of theatre were restricted and met national guidance. Security doors and a buzzer system was in place, with additional lockable doors in child only areas. 
 

The Rivers had a centralised alert system that made all departments aware of an emergency. During this assessment we observed surgery staff responding quickly to a medical emergency in another department. 
 

All areas within surgery were clean and free from clutter. Equipment was serviced and cleaned in line with the services policy. Audits showed good compliance. There was monitoring in place to ensure air flow in theatres was safe and in line with national guidance. Evidence showed action was taken when air quality testing showed low compliance. 
 

Staff had environmental risk and fire safety training. This included the risk assessment and monitoring of battery-operated equipment. Leaders supported fire safety with effective polices and twice-yearly fire evacuation drills. Each department also had a trained fire marshal on duty this ensured a prompt and coordinated approach to environmental emergencies. 
 

Clinical waste and sharps were disposed of correctly and in line with the services policy. 
 

Staff used electronic and some paper care records. These were stored securely and kept safe. 
 

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.

Patients told us staff were knowledgeable and appeared well trained to perform their job role. 
 

We observed all areas had appropriate staffing numbers to patient ratios which were in line with national guidance. The service had an on-call consultant available 24 hours a day to support escalation and incident management. 
 

Safe staffing levels were reviewed daily to support patients’ needs and capacity. Some staff had raised concerns about patient to staff ratios for higher acuity patients. Leaders introduced a new staffing tool in March 2026 which looked to address surgery staff planning. Leaders were working with staff to ensure appropriately trained numbers of staff on each shift to maintain patient safety and support staff wellbeing. 
 

Staff received core mandatory training that was underpinned by additional online or face-to-face update sessions to support staff development. Staff had access to their own mandatory training dashboard and team leaders could monitor staff’s training tracker for completion and address any low compliance. Staff told us they had been supported to develop and upskill. Leaders encouraged staff to train in additional skills that enhanced patient care and safety.
 

New staff received the appropriate pre-employment checks and were supported with a corporate induction and core training underpinned by the service’s regulatory requirements. This was followed by a 3-month probation period with check-ins and peer support. Recruitment processes were supported by policies that ensured equal opportunities for all protected characteristics in line with the Equality Act 2010. 
 

Data showed permanent theatre staff were meeting training compliance at 97%, however bank staff’s compliance was below the 85% compliance target at 75%. Leaders were taking steps to improve bank staff’s compliance with monthly reviews with any associated non-compliance risk being escalated through surgery governance structures. 
 

Surgery consultants were governed under the services credentialing of accredited healthcare professionals’ policy. This outlined the process for application, practicing privileges and ongoing monitoring. Leaders had effective central systems in place to ensure consultants competencies, professional registration and Disclosure and Barring Service (DBS) checks were up to date. We reviewed 5 consultants’ records which were fully completed and compliant with the services policy. 
 

All staff received yearly performance development reviews which supported career progression and staff wellbeing, as well as addressing any areas of low performance or concern. 
 

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.
 

Areas observed throughout surgery were visibly clean and suitable for patients. At time of assessment staff were seen carrying out cleaning of equipment and patient areas regularly. Staff understood their roles and responsibilities towards infection prevention control (IPC). Surgery had an IPC lead that supported good compliance and staff training. Data we reviewed showed good overall compliance with IPC training. 
 

Processes for ensuring risks associated with infection prevention were embedded. For example, all patients undergoing major surgery were screened at pre-admission clinics for Methicillin-Resistant Staphylococcus aureus (MRSA). This is a type of bacteria that usually lives harmlessly on the skin. But if it gets inside the body, it can cause a serious infection that needs immediate treatment with antibiotics.
 

We observed good clinical practice throughout departments and staff completed the appropriate hand hygiene and were bare below the elbow. Compliance was monitored through audits. Hand hygiene audits showed mostly good compliance, however ward areas had below compliance results in February to March 2026. Leaders responded to ensure learning and compliance in April improved to 94.6%. 
 

Surgery areas were inspected weekly following the national ’50 steps’ audit process. This enabled a detailed overview of IPC risks and ensured consistently high levels of cleanliness to meet health and safety standards. 
 

Leaders reviewed all incidents of surgical site infections (SSI) under their Patient Safety Incident Review Framework (PSIRF). These were reported into the UK Health Security Agency. Data from January 2025 to December 2025 showed 0 surgical site infections for hips replacements and 1 for knee replacements.
 

The service had IPC policies and procedures that reflected National Institute for Health and Care Excellence (NICE). Leaders had appropriate oversight and monitoring of IPC measures to ensure patient and staff were kept safe.

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.
 

The service supported the safe use of medicines for surgical patients using a paper-based prescription chart. There were charts specific to surgery and ones which supported after care in recovery. Medicines were administered safely and as prescribed. Staff demonstrated an understanding of how to access and emergency medicine, including naloxone when clinically indicated, and described the ongoing monitoring undertaken to ensure patients remained stable following administration. 
 

Staff discussed preventative antibiotics during team briefs and staff told us pharmacy support was accessed promptly to source alternatives where needed, supporting antimicrobial stewardship (AMS). Venous Thromboembolism (VTE) risk assessments were completed before patients had their surgery, and where required people were prescribed appropriate medication to prevent the formation of a blood clot. 
 

Staff within the service conducted a daily resuscitation huddle with roles allocated at the start of each shift and access with staff where trained in advanced life support and emergency medicine use. 
 

Records we reviewed showed medicines reconciliation had been completed with pharmacist involvement in some cases and batch numbers and expiry dates had been recorded for medicines used in procedures. This is a formal process of creating the most accurate list possible of a patient's current medicines However, pharmacy capacity had affected the consistency of medicines optimisation input, including variable pharmacy involvement in medicines reconciliation. The service was supported by the corporate pharmacy team while staffing pressures were being addressed