The Yorkshire Clinic

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 remained as good. This meant people were safe and protected from avoidable harm.

This service scored 84 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We scored the service as 4. The evidence showed an exceptional standard. The service had a strong, proactive and positive culture of safety, based on openness and complete honesty. They actively listened to concerns about safety and thoroughly investigated and reported safety events. Lessons were always learnt to continually identify and embed good practice.

The Yorkshire Clinic had developed a Standard Operating Policy (SOP) which described how the service will implement the NHS England Patient Safety Incident Response Framework (PSIRF) and Ramsay Patient Safety Incident Response Plan (PSIRP). This replaced the previous serious incident review process. We saw this incident response plan was embedded at the time of inspection and included policy and flow charts, detailed swift reporting, investigation and action planning for all levels of incidents, in accordance with national guidance. For example, the completion of patient safety incident investigations (PSII). We reviewed the flow charts and saw staff were directed to follow three types of learning response depending on the severity and nature of the incident.

Sharing and discussing incidents was actively encouraged and a culture of transparency and risk sharing was nurtured and supported. Staff actively listened to concerns about safety and incidents were thoroughly investigated. We saw swift and comprehensive incident reviews and additional thematic reviews in response to emerging issues. Lessons were always learnt and routinely shared to continually identify and embed good practice and managers took additional steps to ensure learning was understood by all staff.

Staff knew what incidents to report and how to report them, in line with service’s policy and all staff we spoke with were able to articulate recent incidents and the subsequent learning that followed. Learning was clearly embedded within the organisation and staff spoke of safety promotion as a fundamental aspect in every aspect of their role. We reviewed five incidents and saw they were comprehensively investigated with clear action plans, which were completed robustly and swiftly.

Staff were actively involved in identifying, reporting and learning from safety events through the Speaking Up for Safety Programme. This is an evidence-based approach supporting staff to respectfully challenge others regardless of seniority where they have concerns that may compromise patient safety.

The service further developed processes to promote and protect patients from potential harm. We saw the use of swarm huddle and hot debriefs, to ensure staff understood and were able to prevent further incidents quickly. We reviewed deep dives and patient safety incident investigations, which led to national shared thematic work across the Ramsay network. Staff were further supported with close the loop learning reports and patient safety specialists. Patient safety was supported through The Patient Safety Strategy plan, which formed part of the overarching Clinical Strategy.

The service had reported no never events in the previous five years. A never event is a serious incident that is wholly preventable as guidance, or safety recommendations providing strong systemic protective barriers, are available at national level, and should have been implemented by all healthcare providers. They have the potential to cause serious patient harm or death, has occurred in the past and are easily recognisable and clearly defined.

Managers shared learning with their staff about never events that happened elsewhere and across the national organisation within The Ramsay network. When learning was relevant to work done at their hospital it was shared with staff. The service also participated in Ramsay Health wide learning from deaths and staff we spoke with were aware of this national learning also. The service developed a mortality tracker in which unexpected deaths resulting in a PSII were thematically reviewed and actions for learning shared across all teams.

Staff fully understood duty of candour and managers provided evidence on site of swift and honest dialogue with patients and their families following incidents or concerns. They were open, transparent and gave patients and families a full explanation if and when things went wrong. Duty of candour was carried out during the investigation of incidents. Managers investigated incidents thoroughly. We saw face to face meetings were offered on all occasions to ensure families were fully supported when incidents arose.

We scored the service as 4. The evidence showed an exceptional standard. The service always worked with people and healthcare partners to design, establish and maintain safe systems of care, in which safety was always well managed and monitored. They made sure there was always continuity of care, including when people moved between different services.

Patients were able to self-refer into the service through either a privately funded route or NHS pathways. Every patient admitted for surgery followed a comprehensive pre- assessment process supported by the provider pre-operative assessment framework which included robust health checks, risk assessment and overall acceptance for surgical treatment. The framework ensured the optimal health and safety of patients and followed a robust health criterion, which was verified against the hospital's exclusion criteria. This ensured all staff followed clear pathways when accepting patients to ensure safe system entry into the service.

We observed a ward multidisciplinary team (MDT) meeting. This included lead members of the healthcare team including a nurse in charge, ward nursing staff, theatre staff, phlebotomist, physiotherapist, radiographer and healthcare assistants. We observed each person on the ward was discussed with key risks highlighted, diagnostics and results needed prior to surgery and any outlying issues or concerns. All members of the teams had a voice to ensure their clinical expertise was recognised and included within the patients care.

We saw individualised pre-operative assessment care for patients undergoing treatment which included a programme of physiotherapy several weeks prior to joint surgery to ensure patients were in optimal physical fitness. We spoke with several patients who had undertaken this pre-surgery physio support and reported enhanced recovery outcomes, including almost immediate mobilisation following hip replacements.

We observed two patient theatre lists and saw effective systems in place to promote and protect the safety of patients. The service followed National Safety Standards for invasive procedures and World Health Organisation (WHO) surgical safety checklists. We also saw ‘Stop before you block’ posters and guidance attached to equipment such as ultrasound machines. We reviewed clear consent processes and allergy checks as part of the preoperative checklists. Knife to skin commencement times were verbalised to all theatre team staff and time out also clearly communicated. All members of the team were actively engaged in these checks. Following each list we also observed debriefs, which were instigated by the relevant surgeon and led by the operating department practitioner.

We saw clear written and verbal communication to both internal and external healthcare partners, including clinician referral, allied healthcare practitioners and GP colleagues. Medical history and patient self-assessments documentation was comprehensive and all documents we reviewed were completed fully. We also saw clinician review at each point of assessment and evidence of professional challenge where information was unclear.

The service had clear transfer out processes in the event of emergency care or deterioration of patients. The service had developed local processes, including service level agreements with a neighbouring NHS hospital in the event patients required a higher level of care of emergency intervention. We reviewed these transitional plans and saw they were routinely reviewed and updated.

We saw a number of pathways were in place to guide staff through multi-disciplinary team (MDT) processes. We reviewed pathways for pre-assessment and surgical provision and saw these were regularly reviewed. The service also recognised the need to design additional pathways for specific conditions. These included but were not limited to the Hip and Knee enhanced care pathway.

The recognition of safe systems and their implementation formed part of the Patient Safety Strategy within The Yorkshire Clinic.

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.

All staff we spoke with understood safeguarding policies and processes and were able to articulate particular vulnerable patient needs. Staff were also provided with flow charts to guide them, when making a safeguarding alert. Ward staff were able to provide examples of safeguarding alerts they had raised and how patients had been protected from risk of abuse or harm.

The provider had developed a policy which referenced appropriate child and adults safeguarding process. This was in line with intercollegiate guidance and national guidance. All staff we spoke with knew who the designated lead for safeguarding within the hospital was. This lead was supported by heads of department who were all trained to level four safeguarding adults and children level four. Clinical staff were trained to level three. Training compliance figures were high at 100%. Safeguarding training also included female genital mutilation (FGM).

Staff also completed learning disability / autism awareness training. Overall completion compliance was 98% at the time of inspection.

Safeguarding awareness was also covered as part of induction training, and we saw safeguarding supervisors across all departments who met to discuss alerts or incidents as they arose. Flow charts signposting staff as to how and when to make appropriate alerts were seen across all departments.

We also reviewed recruitment policies and saw appropriate disclosure and barring checks were carried out for all staff, as appropriate. We reviewed four staffing files and saw checks were in place, in line with the providers policy.

We scored the service as 3. The evidence showed a good standard. The service a worked well with people to understand and manage risks. They provided care that met people’s needs and was safe, supportive and enabled people to do the things that mattered to them.

Risks to each person's health and well-being had been fully reviewed as part of the pre-op assessment process and then further reviewed on the ward as part of a comprehensive admission assessment. These included risks relating to people's mobility, skin care and nutritional needs. We reviewed patient records and found evidence of bedrails assessment, falls assessment template, repositioning and PURPOSE-T (Pressure Ulcer risk primary or secondary evaluation tool) skin for skin integrity.

Patients we spoke to felt they had been fully informed regarding their planned care and told us they had chosen to have their surgery here on multiple occasions. Patients had access to information within the pre-assessment areas regarding advice on staying well for surgery and this was available in a variety of formats.

There were processes to ensure patients risks were assessed, monitored, and managed on a daily basis.

All surgical procedures at The Yorkshire Clinic were elective and patients requiring surgery were supported by 24/7 on call anaesthetic provision. We saw clear inclusion and exclusion criteria in place to ensure ceilings of care were met and not exceeded. The Clinic had further developed processes to ensure compliance with this criteria by introducing several touch points to ensure consultants assessed patients in line with this criteria such as referral point and the consultant review.

We observed staff safety huddles as part of our inspection, which ensured risks were shared with all colleagues present.

We saw evidence of nationally recognised risk assessments in patient notes including for falls, nutrition, pressure ulcers and VTE (venous thromboembolism). We reviewed six separate patient documents and saw these had been completed fully and to a high standard.

In addition, the service had developed algorithms and clear processes for the acute management of bradycardia, coronary syndrome, tachycardia, refractory anaphylaxis and hypoglycaemia for patients with diabetes. We reviewed these processes and saw that they were clearly defined and outlined patients that were safe to be appropriately managed within the clinic, or those that would be referred to NHS providers.

Angiography and cardiac diagnostics are performed on site but only for non-acute presentations. These include stable bradycardia and non-acute chest pain. The service was available to patients who are already known to have coronary issues or are referred for elective investigation. The clinic did not manage acute coronary syndromes and such patients were also referred back to NHS services.

The service had implemented protocols for the surveillance of surgical site infections including 30 day surveillance management processes. This included the distribution of a post operative patient questionnaire relating to wound healing, signs of infection and any healthcare interactions post discharge. We reviewed the most recent surveillance outcomes and saw over 99% of patients are successfully contacted or return their forms and the clinic consistently maintained infection rates below national benchmarks.

We reviewed standard operating procedures for unexpected or significant findings for patients undergoing diagnostic imaging or tests and saw these were regularly updated and ratified.

The service held ‘safari’ scenarios every week and rotated clinicians, to ensure all staff were fully trained to provide emergency resuscitation. Managers ensured all clinical staff were involved in these drills to maintain clinical skills. These scenarios were timed and measured against national best practice to ensure optimal outcomes for patients. These skills were documented and reviewed in addition to mandatory training requirements.

Staff also told us about weekly patient safety meetings within surgery. We saw these were well attended with clear learning documented.

The provider held briefs at the start of each shift for staff which incorporated clear risk identification for each patient receiving care and treatment that day. Staff demonstrated a robust understanding of people’s needs and how to positively support them with their known or developing risks. These included signs of deteriorating health, medical emergencies or behaviours that may challenge.

A member of staff told us about the proactive work undertaken prior to surgery to enable patients to not only recover but also physically become stronger to enhance recovery and ultimately mobilise sooner.

Patients on the wards were able to access help if they had concerns through use of call bell systems. We saw nursing staff routinely interact with patients continuously throughout the day, to provide discreet safe observation but also to ensure all needs were met.

Staff told us about processes for escalation of patients. We reviewed the providers process for the transfer of critically unwell patients and saw this was supported by a transfer flow chart to ensure swift action was taken by staff. We saw clear parameters were in place to ensure patients were escalated swiftly in the event of an emergency or transfer out.

In addition, we saw a service level agreement was also in place for the provision of anaesthetic support for medical patients, patients that require anaesthetic assessment due to deterioration in condition post-surgery and patients who require transfer for a higher level of care. We reviewed this agreement and saw clear processes to ensure that patients being transferred for level 2 or 3 or care would be escorted by a consultant anaesthetist to ensure airway was continuously monitored.

We reviewed data to show the numbers of patients who were transferred out when compared to admission figures and saw that this equated to 0.10% of patient admissions across the last twelve months.

There was a nationally recognised system in place based on clinical assessment of patients to determine level of deterioration (NEWS). Regular documentation audits ensured high levels of compliance and escalation where appropriate to ensure compliance against local policy and national best practice. We reviewed six sets of patient records during our inspection and found them to be fully and comprehensively completed. We saw the service had developed a track and trigger tool to support swift escalation of deteriorating patients.

The service had also developed blood services and antimicrobial stewardship with external providers to enhance patient safety and in addition, had also developed a service level agreement with a local haematology service to provide immediate and ongoing advice regarding the prevention of VTE, surgical bridging and thrombosis.

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 service had received Joint Advisory Group (JAG) accreditation in January 2025 for its endoscopy services, which were shown to have met best practice quality standards.

Access to the hospital was through the main ground floor reception, which was manned seven days a week. There was also an outside access control system to get in and out during out of hours along with a with a sign in and out system. Signage to the wards and outpatient areas was clear and we saw staff providing care and support to patients and their families as they arrived.

Patients to be admitted, were guided to one of two wards. One of which had been fully refurbished to a high standard, but we did not include this as part of our assessment, as there were no patients in residence, at that time.

The ward and surrounding environment were visibly clean, tidy and well-maintained. All rooms were single occupancy with ensuite bathroom and call bell facility. Rooms also displayed a digital nurse allocation name above each door.

Sluice rooms, cleaning cupboards and store rooms were all found to be locked and secure. Sharps were managed in accordance with the providers policy and we saw they were below the maximum fill levels in all areas we inspected.

The service carried out several Patient Safety National Safety Standard inspections (NatSSIPS) including WHO surgical safety checklists. We reviewed the most recent audit dated February 2025 and saw the service scored 100% compliance.

The service also completed a prosthesis inspection report, with the most recent report dated January 2025 score 100%. The providers Stop Before You Block inspection report dated April 2025 scored 98.6%, with the one action identified resolved immediately following the inspection.

Ward and departmental audits and daily checks were carried out by nominated staff to ensure that the environment and equipment used was safe and fit for purpose. We checked fifteen portable pieces of patient equipment and found them to be serviced and in working order. Equipment to safely manage bariatric patients was also evident.

Staff made sure areas were clean and updated cleaning records. We saw completed cleaning records which were dated and signed. These were monitored by the infection prevention and control lead and actioned by the appropriate leads within each department.

All staff told us they had sufficient equipment and leaders of the organisation routinely reviewed department stock to ensure patients had all equipment that was required. We saw pre assessment questions also relating to the need for specialist equipment. Staff told us they had never been refused a purchase request for equipment. However, we saw three operations were cancelled as a result of unavailable equipment. This included an insufficient retractor, insufficient supplementary kit and a missing noiles hinge. We saw surgery was rebooked and carried out less than a week later in all cases.

Theatres were found to be secure and crash alarms in place in the event of an emergency and were also subject to safari drills.

The building fire risk assessments were routinely reviewed and there were no outstanding actions at the time of the inspection. Fire escapes were clear and we saw regular fire drills were carried out by the provider.

The service had a robust business continuity plan, in the event that there was significant interruption to the service. This had recently been reviewed in January 2025 and included collaboration with neighbouring services, key contacts and detailed steps to be taken to ensure the safety of patients.

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 support, supervision and development opportunities. They worked together to provide safe care that met people’s individual needs.

Feedback from patients demonstrated they felt there were enough skilled staff to meet their needs. Comments provided to us by patients included ‘Plenty of opportunities to ask questions’, the care has been ‘Very good’ and ‘My family have also had surgery here’

Leaders of the service told us staffing was reviewed at least two weeks ahead of theatre lists, to ensure adequate staffing was in place to meet every patient’s clinical needs. Staff told us if patients required additional 1:1 support this could also be accommodated within the staffing numbers. For example, patients experiencing anxiety or delirium.

Each department was supported by a lead nurse and also a number of senior nursing staff. We reviewed skill mix during the inspection and found a high number of senior nursing staff, with several years of nursing experience within the surgical field. In addition, we found the majority of staff both nursing and allied staff had worked at the hospital for several years and spoke with pride regarding their loyalty to the team. We reviewed staffing levels on the inpatient ward and saw a 1:5 patient to staff ratio.

The Yorkshire Clinic follow The Association for Perioperative Practice (AfPP) guidelines to ensure theatre lists have the correct staff requirements (numbers and skill mix).

We reviewed staffing across two recent months and saw that staffing levels in theatres met these guidelines continually, with no gaps in staffing rotas. In addition, a senior registered practitioner worked supernumerary as shift co-ordinator in addition to the theatre manager or deputy. We also reviewed medical cover and again saw robust cover processes and rostering in place to ensure immediate patient review post-surgery or in the event of deterioration. The planned number of medical staff matched the actual numbers and we saw on call consultant rotas were in place. In addition, and uniquely, the hospital ensured they had anaesthetic on call cover seven days a week, 24hrs a day.

Patients told us they received timely visits and advice from all staff involved in their care and staff told us there were sufficient numbers of both nursing and medical staff.

Imaging was performed and interpreted immediately by a consultant radiologist.

Nursing staff told us that all new staff would have an induction, during this time they were supernumerary, and the induction would be tailored to meet their needs depending upon previous experience. We reviewed the induction and saw it was detailed and was adapted to specific roles. All staff met with the senior leadership team as part of this induction. All staff were required to complete a bespoke clinical competency training pack to further support their role. This was part of the Yorkshire Clinic supervision framework which outlined the organisations commitment to its staff regarding reflection on clinical practice.

We met with one of the nurse educators, who provided a list of courses for staff to undertake. These included mandatory training and additional courses. We also saw a number of in-house training sessions, which were delivered by existing staff. These included hypernatremia, sepsis and extra NEWS training following on from incidents or to enhance learning. We reviewed this incident relating to NEWs score and saw a comprehensive review of the incident, which identified that the NEWS 2 track and trigger tool was not followed and the resident medical officer was not informed immediately, when the patients score was 5. We saw clear actions taken as a result of this review, which would support earlier detection and potential avoidance of transfer out for future patients.

Training was also offered as lunch time sessions to enable as many staff to attend as possible.
Staff provided many examples of courses they had requested, which were in addition to their usual training. For example, bespoke learning disability training which was requested and provided to support a specific individuals journey and additional electro cardiology training. External speakers were brought in for some areas of training as and when required.

We saw the service had appointed a Resuscitation Lead who audited the safari crash calls and ensured all staff were involved in the resuscitation practice scenarios.

A ‘Speak Up For Safety’ trainer was also in place and we saw Speak Up For Safety champions across all departments we visited. All staff were aware of these roles and the support that they provided.

Mandatory training compliance was reviewed during our assessment and was scored at 99%.

All staff had also completed Oliver McGowan autism awareness training.

We scored the service as 4. The evidence showed an exceptional standard. The service thoroughly assessed and managed the risk of infection. They always quickly detected and controlled the risk of it spreading and always shared concerns with appropriate agencies promptly.

All departments including waiting areas and corridors were visibly clean. Housekeeping staff were active throughout the ward areas throughout our visit and we saw cleaning schedules specific to each clinical area, completed and up to date. Hand gel was readily available throughout the hospital and best handwashing practice was actively encouraged through visual posters and regular auditing.

Linen and patient bedding were appropriately stored in all areas we reviewed.

The service had appointed an IPC lead, who held overall responsibility for audit completion and the submission of audit results. This lead reported to the Deputy Head of Clinical Services and ensured IPC link staff were in every department throughout the hospital and four housekeepers had also completed train the trainer competencies to ensure the service complied with national cleaning specifications. There was an IPC committee that met quarterly with clear terms of reference, chaired by a Consultant Microbiologist and attended by MDT leads across departments ensuring robust governance and cross-functional accountability both within the hospital and with the wider local community.

We also saw aseptic non-touch technique (ANTT) trainers in theatre, diagnostics, angiography, ward and outpatients. ANTT e-learning was mandated through the electronic recording system and monitored by each head of department. The service had achieved ANTT Gold accreditation demonstrating aseptic technique was embedded across all clinical teams.’

The Clinic carried out ‘objective auditing’ to measure Infection Prevention and Control practices and policy compliance. The audits formed part of the assurance that the training, education and plans worked to protect patients from infections. This also included a twice monthly 50 steps of cleaning audit in theatres and monthly audits in all other clinical areas. In addition, the service carried out decontamination audits. We reviewed the most recent audits and saw compliance was consistently high at 98% In the January 2025 decontamination sterile inspection audit. The service also carried out environmental audits which showed decontamination of endoscopy inspection scored 97% compliance.

The clinic had zero healthcare associated infections for the mandated UKSHA organisms. These included MRSA bacterium, MSSA bacterium, E coli bacterium, Klebsiella and Clostridium difficile.

Surgical site infections: PHE Surgical Surveillance Scheme (SSIS) were reported. We saw for the twelve-month period from January 2024 to December 2024 there were no knee arthroplasty infections reported and three hip arthroplasty infections reported. We saw a systematic review was undertaken and actions to improve included but were not limited to documentation, pre-assessment documentation, documented aseptic technique at wound check.

We also saw the provider undertook systematic reviews of all other infections noted across the service, which formed part of an extensive annual report to the board. These reviews were shared within the Ramsay network to enhance practice development. The Infection Prevention and Control Annual Report was produced for the service which highlighted the overall achievements of the service and included but was not exclusive to, surgical site infections by speciality, swab culture data, environmental audit data, food hygiene rating scores for the kitchen areas and national learning across the Ramsay network.

As part of the learning following incidents, we saw the provider had introduced wound care leaflets with QR codes. In addition, all registered nurses were required to complete wound care e learning training in 2025.

Each day leads of departments were required to undertake daily compliance checks lists, which focused on the visible cleanliness of the departments. We also saw commitment to cleanliness star ratings across departments and saw they were recently awarded with the maximum five-star rating given.

The service also participated in sharps audits which were completed to ensure compliance with best practice of disposal.

We also reviewed the most recent hand hygiene audits and saw these were 100% compliant, in the March 2025 report.

The service scored 91% when undertaking the urinary catheterization bundle audit.

Peripheral venous cannula care bundle audit scored 100% on the ward and 90% in theatres. We saw action plans for all audits undertaken.

The provider delivered IPC sessions to local schools as part of an outreach programme to educate children about hand hygiene.

The service followed the ‘National Infection Prevention and Control Manual for England’s standards and set out to demonstrate compliance with the ten criteria of the ‘Health and Social Care Act 2008, Code of Practice on the Prevention and Control of Infections and related guidance.

Members of the housekeeping team successfully completed The British Institute of Cleaning Science (BICS) Cleaning programme in 2024. The aim was to roll out this training to all housekeeping team members in 2025. We saw this roll out had commenced at the time of the inspection.

All patients were screened for cold and flu symptoms prior to admission and a risk assessment was completed for communicable diseases if appropriate.

Surveillance checks were completed for patients 30 days post-surgery. These were carried out to check for signs of wound infection. We reviewed the most recent checks and saw 100% compliance.

Wound care training was delivered to staff on site and antimicrobial stewardship was done in partnership with local pharmacists to ensure that appropriate antibiotics were prescribed and administered swiftly, rather than prescribe broad spectrum medicines. A microbiologist was available for advice for all staff and reviewed all infections as well as chairing the quarterly IPC meetings.

Patients’ temperatures were monitored prior to, during and following surgery. The provider followed evidence-based practice which showed keeping the patients warm was shown to reduce the risk of infections. Warming blankets were used where necessary to keep the patient’s temperature at an optimal level. The service also collated evidence following the implementation of this practice which showed improved healing and post-surgical recovery.

As part of the mandatory hand hygiene training and induction, all staff received a skin check, to check for dryness, irritation or signs of dermatitis. Any staff showing symptoms were provided with additional support, including pocket sized bottles of hand lotion and GP referrals where required to occupational health. Staff receiving this additional support were reviewed as part of an ongoing process by the IPC lead.

We reviewed IPC training compliance scores across the service and saw it was 99%. This included face to face training and practical sessions regarding hand hygiene.

We reviewed the most recent Patient Lead Assessment of the Care Environment (PLACE) saw the service was scored 99.63%.

The Yorkshire Clinic maintained the highest Environmental health Hygiene rating score of five.

The service also carried out antimicrobial prudent prescribing indicator auditing, to ensure most appropriate use of prescribing specific medicines.

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.

The service had a medicines management policy and the service stored medicines securely in line with this policy. This included prescription pads. The service had systems to ensure staff knew about safety alerts and incidents, this helped to ensure that patients received their medicines safely.

The pharmacy department worked core hours with an on-call pharmacist available out of hours. The service ensured medicines reconciliation were completed at several stages of the patient's journey. The service ensures level 2 (L2) medicines history is undertaken at ward level by a pharmacy technician within 24 hours, in addition to medicines checks at admission and discharge. Medicines reconciliation is a critical component of inpatient pharmaceutical care, aimed at ensuring the accuracy and continuity of a patient’s medication upon hospital admission. Anyone found to be prescribed warfarin, for example at pre-assessment, was referred to specialist consultant for a review and to agree a management plan.

During the inspection, we did not see any documented missed doses on patient’s drug administration records. Records were fully completed and comprehensive. Controlled drug stock checks were routinely completed by two members of staff and subject to regular auditing.

Staff told us they had a good relationship with the pharmacy team and we observed proactive multi-disciplinary team working during our inspection.

The Yorkshire Clinic has also embedded a robust referral pathway for patients identified during pre-assessment as being on high-risk medications. This proactive service ensures that such patients are referred directly to a pharmacist for a comprehensive medication review and management plan spanning the pre-surgical, peri-surgical, and post-operative phases of their care. By facilitating early identification and timely intervention, the pathway minimises the risk of medication-related complications and reduces the likelihood of surgical delays or cancellations. It also supports seamless continuity of care through individualised medication planning tailored to each patient’s clinical needs.

The Yorkshire Clinic had enhanced patient accessibility and continuity of care through the implementation of a Medicines Home Delivery Service, a compassionate initiative designed to support those unable to collect essential medications on-site. This formed part of The Yorkshire Clinic’s commitment and values to patient wellbeing and to delivering outstanding, inclusive healthcare solutions.

The service also provided complex medicines support for each patient. This included diabetic and anti-coagulation medicines.

Following minor surgery procedures in the outpatient's department, patients were sent home with discharge advice. This included advice about pain relief medicines and any medicines they were taking home with them.

The service had a Medicines Optimisation (including Medical Gases) Group. The Medicines Optimisation Group met bi-monthly. Staff discussed medicines safety alerts and incidents, and they shared learning and actions, so everyone was aware of these.

Temperature logs for clinical rooms and medicine fridges were documented automatically on the central electronic system. This notified pharmacy if the temperatures went out of range. We saw this working effectively as part of our assessment.

Venous Thromboembolism (VTE) risk assessments were carried out pre-operatively to ensure patients would be prescribed the correct anticoagulant during their stay.