The Beardwood 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

This means we looked for evidence that people were protected from abuse and avoidable harm. We assessed 8 quality statements.

At our last assessment we rated this key question as requires improvement. At this assessment, the rating had improved to good.

Good: This meant people were safe and protected from avoidable harm.

We looked for evidence that safety was important for all staff including leaders with an open learning culture. We ensured people were protected from avoidable harm by staff who were trained and competent to treat people in their care. We checked that the environment was appropriate and visibly clean with safe processes including medicines management.

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 have a proactive and positive culture of safety based on openness and honesty, in which concerns about safety are listened to, safety events are investigated and reported thoroughly, and lessons are learned to continually identify and embed good practices.

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 we spoke with knew how to report an incident and were familiar with duty of candour. Duty of candour is a legal and ethical requirement in healthcare to be open and transparent with people receiving care. It applies to every health and social care provider that CQC regulates.

All staff received feedback from incidents, or complaints, via daily communication meetings, safety huddles and videos. Information was shared in weekly clinical bulletins and monthly newsletters.

Examples of how learning from incidents and complaints had taken place were provided.

We work with people and our partners to establish and maintain safe systems of care, in which safety is managed, monitored and assured. We ensure continuity of care, including when people move between different services.

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 received referrals from a number of sources including NHS providers such as GP’s and choose and book. Patients could also self-fund if they met the criteria.

There was an exclusion criteria for elective surgical admissions. They were deemed a level zero site meaning operations expecting to be routine could be performed there. Patients whose needs were stable and could be managed on a standard hospital ward without intensive monitoring could be accepted if they met the criteria.

Following consultation with a surgeon where risks and benefits of surgery were discussed and informed written consent was obtained; patients attended a pre-operative assessment. Tests were carried out to ensure the patient was suitable for the surgery. Any concerns highlighted could mean further discussion with medical staff such as the consultant surgeon, anaesthetist or GP. Staff provided patients with information to support discussions including any preparation for the day of surgery.

On admission, patients followed specific pathways dependent on the surgery being performed. Risk assessments were carried out dependent on the individual patient. There were visual aids to remind staff regarding specific needs such as falls champions.

There was a provider policy for care of the deteriorating patient that highlighted escalation procedures to clinical staff dependent on scores. In the 12 months prior to inspection there had been 4 patients who needed to be transferred to the local NHS trust, one of which was diagnosed with sepsis. Sepsis management was included in the care of the deteriorating patient policy. These patients were followed up and the incidents graded as low and no harm.

There was a provider discharge and planned transfer of care policy. This provided guidance regarding discharge processes and also included information about how to support patients who raised concerns post discharge.

We work with people to understand what being safe means to them as well as with our partners on the best way to achieve this. We concentrate on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect, and we make sure we share concerns quickly and appropriately.

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.

There were provider policies for safeguarding children and young people and safeguarding adults. Information regarding local safeguarding procedures was displayed on a notice board for staff to follow.

Staff completed safeguarding training as part of mandatory requirements. Compliance was 96% for adults safeguarding level 3 and 96% for adult safeguarding level 2. For children’s safeguarding, compliance was 97% for level 2 and 100% for level 3.

Staff knew how to make a referral or who to contact for support. In the 12 months prior to inspection there had been two safeguarding referrals for surgical patients.

We work with people to understand and manage risks by thinking holistically so that care meets their needs in a way that is safe and supportive and enables them to do the things that matter to them.

3. 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.

On the day of admission for surgery information was discussed with the patient to support their hospital stay. General admission details were taken and recorded in specific pathway documentation. Risk assessments, such as those for falls and pressure ulcers were also completed on admission to assess any additional needs.

A theatre briefing took place prior to the surgery. Any patient identified with a specific requirement such as a someone with time-critical medicines such as a diabetic patient or diagnosed with Parkinson’s Disease would be positioned at the beginning of the list.

Patients with dementia were nursed close to the nurse’s station. Additional staffing could be sourced if needed.

In theatres, we observed that the World Health Organisation’s (WHO) Checklists were competed appropriately. The WHO checklist is a patient safety tool designed to reduce surgical errors and complications by improving team communication and confirming critical steps before, during, and after operations. Audits between November 2024 and October 2025 showed compliance of 98% to 100%. We observed a positive culture in theatre that empowered staff to ‘stop the line.’ This meant that any staff member could halt a procedure if they saw a potential safety risk.

We detect and control potential risks in the care environment and make sure that the equipment, facilities and technology support the delivery of safe care.

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.

Access to the ward was safe and secure. Patients were required to enter the hospital via the main entrance where they were greeted by staff and escorted to the ward. Additional security had been added to the entrance door.

Entry to treatment rooms where medicines were stored were accessed only by staff cards / key pads.

The ward had 18 spacious ensuite private rooms that included satellite TV and a telephone. There was also a six bedded day-case suite and an area where minor procedures took place with recliner chairs for comfort. For the six-bedded ambulatory care area, there were trolleys in cubicles with curtains. There were plans to change this to add perspex frontage for privacy reasons. There were three main theatres as well as the minor procedures area.

The ward and pre operative assessment were on the ground floor. There were two lifts available if a need for accessing other floors by hospital staff.

The provider maintained an asset register of all equipment utilised by the service. This showed that the provider had oversight of equipment that was in service at the location. There was an uninterruptible power supply (UPS) in case of a power failure during procedures. A UPS is a device with batteries that provides instant, short-term backup power to electronics when the main electricity fails, preventing sudden shutdowns, data loss, and equipment damage from power surges, spikes, sags, and interference. Information showed that the back-up generator had been serviced within the 12 months prior to inspection. Examples of equipment we saw in clinical areas included stickers to indicate checks in the 12 months prior to inspection. Equipment was removed from service if in need of repair or past the date of routine maintenance.

There were resuscitation trolleys available in case of an emergency as well as first aid boxes in reception areas. We noted that the equipment in theatre and on the ward had been checked regularly. An item that was passed its expiry date, in the resuscitation trolley, was replaced when we were onsite.

There were plans for equipment that was in need of replacement or additional to current stock items. The service had planned projects for improvement such as security added to the ward entry door and the refurbishment of two anaesthetic rooms that was on the risk register. Future improvements had been planned in a phased way up to 2030.

We noted a fire door that was being propped open by a bin. This was escalated and closed immediately. Following a fire inspection in 2023, a number of recommendations were made. The actions have now been completed except for two graded as moderate that are in progress. A fire evacuation drill took place in May 2025 that went well. Bespoke practical fire evacuation training took place in theatres in September 2025.

The service had a contract with an external company for the treatment of water. Monthly visits had occurred between March 2024 and August 2024, however the next visit was November 2025. Legionella testing had taken place in May 2024 and November 2024; These showed that there was no legionella detected in the areas tested.

We make sure there are enough qualified, skilled and experienced people, who receive effective support, supervision and development and work together effectively to provide safe care that meets people’s individual needs.

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.

We spoke with a range of staff, during our onsite visit including senior managers, the ward manager, registered nurses, health care assistants, the ward clerk lead, the resuscitation and training lead, the RMO, consultants, the porter and domestic staff.

At the time of the inspection there were interim arrangements for leadership on the ward, however a ward manger had been appointed. There was a safer staffing tool that was used to ensure adequate numbers on the ward that was calculated according to the type of surgery expected. There was a combination of shift times to ensure sufficient numbers at busier times of day.

Between September 2024 and August 2025, there was an average sickness rate of 3%. Between November 2024 and October 2025, there was an average turnover of staff of 13%. Any shortfalls in staffing were filled with regular bank or agency staff. At the time of inspection staff had been appointed to vacancies meaning they then would be fully staffed by December 2025.

All new starters received an induction. There was a provider training matrix for mandatory requirements. This included a combination of face to face and electronic training modules that were role specific such as infection, prevention and control, adult resuscitation, medicines management, moving and handling, the Oliver MacGowan training on learning disability and autism, care and communication of the deteriorating patient, care and communication of the deteriorating patient, information governance, conflict resolution, dementia awareness and safeguarding.

Overall compliance with mandatory training was 97%. All individual modules were greater than 95% compliant. The provider had a competency and skills framework for staff to follow. The service had oversight of modules completed and dates for upcoming refresher training. Staff were required to complete an individual appraisal and were up to date. There was also a range of display boards, in the ward, to support staff training such as blood transfusion.

The service had trained nine members of staff in advanced life support which was above the requirement for the location.

Nurses were supported by other clinical staff that included surgeons who carried out the operations and the resident medical officer (RMO). The RMO was employed by an agency who supplied medical cover services to the provider. The RMO was on site for one week and then was off for a week. During the week on site the RMO was on site 24 hours a day and available overnight if required. They had day to day duties such as daily ward rounds of the in patients, prescriptions for pain relief and discharges, reviewing of results in preoperative clinic and review of patients of concern. The RMO was available overnight on-call if needed. Consultant surgeons could attend, if necessary, within 30 minutes.

Medical staff were employed following a practising privileges policy. There was a medical advisory committee (MAC) who quarterly. This was attended by heads of departments as well as doctors. Set agenda items included discussions of incidents, outcomes, recruitment and future plans. Beardwood Hospital employed 146 Consultants with practising privileges of which 122 was their primary location for the provider. Staff received role-specific training and had completed appraisals, to care for patients and attended team meetings for updates. There were opportunities to participate in additional training if requested.

At the time of inspection, we were told examples of when values not in line with the organisation were managed.

We reviewed recruitment files for five members of staff and found that these were completed with the necessary documents required prior to on boarding with the organisation.

We assess and manage the risk of infection, detect and control the risk of it spreading and share any concerns with appropriate agencies promptly.

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.

All areas and equipment we inspected looked visibly clean and well maintained.

Daily checklists were completed in all areas. Deep cleaning was completed by an external organisation in theatre in March 2025 and August 2025. The main theatres had laminar air flow. This means that continuous streams of filtered air push contaminants away from the patient to reduce surgical site infections (SSIs) for high-risk procedures like joint surgery. Annual ventilation inspection and verification had taken place in January 2025 in minor operations theatre and the three main theatres.

At the last inspection, surgical site infections (SSI’s) were not included in incidents reported. However, at this inspection, a comprehensive spreadsheet of incidents was provided that included SSI’s and demonstrated the provider had taken appropriate actions.

There was a provider infection, prevention and control (IPC) manual for staff to follow. In the 12 months prior to inspection there were 29 infections recorded, one of which was recorded as moderate harm. All other infections were graded as no or low harm.

Hand-washing facilities and personal protective equipment (PPE) were available in all areas including hand sanitisers. There was an information board for patients, visitors and staff that showed hand washing instructions, appropriateness of wearing gloves, sharps disposal and audit information.

The service had promoted national infection prevention week 2025 with daily posters. Theatre was observed to be compliant with national guidance.

IPC and housekeeping audits were completed monthly.

In the 12 months prior to inspection for the providers IPC general principles and practices audit, compliance had improved from 94% to 98%.

For the IPC theatre asepsis audit, compliance was 98% to 99%. For peripheral venous cannulation (PVC) compliance had improved from 83% in February 2025 to 98% in October 2025. For IPC aseptic non touch technique (ANTT), compliance was between 99% and 100%. Between December 2024 and August 2025, compliance with hand hygiene audits was 98% to 100%. Peripheral venous cannulation is a procedure where a small, hollow plastic tube (cannula) is inserted into a vein (like in the hand or forearm) to access the bloodstream. ANTT is a method in healthcare to prevent infection during invasive procedures by protecting "key parts" (sterile equipment parts touching patients) and "key sites" (patient entry points like wounds) from contamination by healthcare workers, equipment, or the environment, using strict hygiene.

Following a focus on IPC in the 12 months prior to inspection, The provider had identified an 80% decrease in infections compared to November 2024.

We make sure that medicines and treatments are safe and meet people’s needs, capacities and preferences by enabling them to be involved in planning, including when changes happen.

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 provider had a safe management of medicines policy as well as a code of practice for controlled drugs. All medicines were prescribed by medical practitioners such as the RMO or anaesthetists.

Medicines were stored securely and overseen by the pharmacy team that were available during office hours. There was good multi-disciplinary working between the doctors and pharmacists.

The service completed medicines audits. Compliance from March 2025 to August 2025 showed compliance of 99% to 100%.