The Beaumont 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 rated safe as good.

The service had enough staff to care for people and keep them safe. Staff had training in key skills and managed infection risks well. They assessed risks to people and acted on them. Premises, facilities and equipment were clean and well-maintained. However, we observed one medicine-related incident that was not investigated in a timely manner. The service was focused on improving learning from medicine related incidents to improve practice.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People who use the service told us they felt safe and did not have any concerns.

Staff identified, reported and managed incidents in line with the provider's incident reporting policy. Staff told us they were encouraged to raise concerns and could easily access the electronic incident reporting system.

Staff we spoke with could describe recent incidents and told us they attend post incident huddles. This enabled them to reflect on the incident as a team and identify learning points.

Managers shared incidents with staff at team meetings and this included incidents from the provider's other hospitals. We reviewed theatre and ward team meeting minutes from September and November 2024 which showed incidents had been recorded and discussed. The minutes documented how lessons learnt had resulted in improvements being made such as height and weight being recorded on admission to enhance the risk assessment process.

Serious incidents were reported centrally to the corporate provider and the service reported these incidents appropriately to CQC. Senior leaders told us that all incidents rated moderate harm or above were shared with the provider's other hospitals. They gave examples of changes that had been implemented following incidents at other sites. Themes and trends were shared with staff electronically and through team meetings.

There had been no never events reported at the hospital in the previous 12 months. A never event is a serious, wholly preventable patient safety incident that should not occur if the available preventative measures have been implemented by healthcare providers.

Senior leaders told us that the reporting culture had improved over the last 12 months. They were focused on supporting staff to further improve the quality and detail used when recording incidents on the reporting system.

Incidents were investigated by senior staff with the appropriate level of training. Incident records were completed appropriately, and remedial actions were put in place to aid learning and improvement. Lessons learned from safety incidents resulted in changes that improved care for others. However, we found a delay in investigating one medicines related incident due to staff absence.

Staff we spoke with understood the duty of candour. The duty of candour is a regulatory duty that relates to openness and transparency with patients if their treatment causes or has the potential to cause harm or distress. The service had a duty of candour policy and staff followed this process for any incidents rated moderate harm and above.

People who use the service told us that they had confidently chosen the hospital and consented to the referral by their GP. They reported a collaborative approach and good communication between the hospital and their GP. They told us they had a pre-operative assessment to determine their needs and preferences.

The service had exclusion criteria that identified people with complex needs who could not be admitted for treatment. The hospital had relevant policies and service level agreements in place. This included an agreement with the nearest NHS hospitals for emergency blood supplies and the transfer of deteriorating patients. A handover of nursing and medical records was completed when a person was transferred to another service or discharged.

Staff understood how to manage people’s risks during an emergency. They told us they carried out routine observations during treatment and people whose health deteriorated were escalated for medical input and promptly transferred to hospital if they required emergency treatment.

The service had daily MDT (multidisciplinary team) safety huddles that included the hospital executive director. We attended one of the safety huddles and observed that the team discussed serious incidents, equipment issues, patient risk, safeguarding, discharges and staffing levels.

Many staff we spoke with described the process they followed if they observed a patient safety risk. They explained they work to the ‘stop the line’ principle whereby all members of the care team are empowered to raise a concern about a patient’s safety or treatment at any time and this would be reviewed.

We collected feedback from two external partner services that worked collaboratively with the service. Partner feedback was very positive about safety and continuity of care. They said regular meetings had enhanced the management and oversight of patients and minimised waiting times for appointments. They told us that they had strong links with the managers and that staff were dedicated, proactive and committed to patient care.

A partner from a local NHS trust told us that the system for transferring patients was very efficient. They told us the service had significantly supported their elective activity and increased capacity at the local NHS hospital.

The views of people who use the service were listened to and considered through participation groups or surveys. The service used the results to make changes and improvements to patient care and safety.

People who use the service told us they had not experienced any instances of abuse or neglect at the service.

The service provided training in line with best practice. Although the hospital did not provide services for children and young people, staff were required to complete level 2 child safeguarding training. Records for the current training year showed that all theatre and ward staff had completed both level 2 adults and child safeguarding training. Similarly, 99% of eligible staff had completed level 3 adult safeguarding training. All eligible staff had completed counter-terrorism strategy training.

The service had a safeguarding lead who had completed the higher level of safeguarding training for children and adults. Staff understood how to make a safeguarding referral and who to inform if they had concerns. They knew how to access support from the safeguarding team.

The provider’s safeguarding policy instructed staff on how to identify and report any safeguarding concerns, including making referrals internally and to external agencies, such as the local authority safeguarding team. The staff we spoke with were aware of the provider’s safeguarding policy.

Staff told us that learning from any reported safeguarding incidents was shared as part of daily huddles and during routine staff meetings. Staff had safeguarding supervision with managers to discuss specific cases and to reflect on the actions and outcomes.

The service had a safeguarding sub-committee and shared reports at the monthly clinical governance committee meetings.

People who use the service told us staff explained any risks associated with their treatment and kept them up to date about any changes to their care and treatment. They told us they received post operation phone calls within 24 hours of being discharged and had support if they needed it.

Ward staff were responsible for post operation contact with patients for the first 48 hours and then outpatients staff took over responsibility. The service planned to audit post operation communications from January 2025.

Staff understood how to identify and manage risks. They told us they regularly reviewed risk assessments and discussed any changes with people and their relatives or carers. Staff told us new or emerging safety risks were discussed during daily safety huddles.

Staff knew how to identify and manage people with suspected sepsis or those whose health deteriorated. Staff used the recognised national early warning score systems (NEWS2) to identify deteriorating patients. They told us that they would escalate deteriorating patients, and conditions such as venous thromboembolism (VTE — blood clots), to the resident medical officer (RMO). The RMO was available 24 hours a day.

We observed theatre teams undertake the `five steps to safer surgery' procedures, including the use of the World Health Organization (WHO) checklist. The theatre staff completed safety checks before, during and after surgery and demonstrated a good understanding of the `five steps to safer surgery' procedures. The service audited compliance for completion of the WHO checklist and data shared by the service showed the department had scored 100% between May and October 2024. This demonstrated full staff compliance.

People who use the service received a pre-operative assessment to identify key risks and their needs and preferences. Risk assessments were reviewed regularly or if there had been any change to a person's condition.

People's risks were discussed during daily safety huddles and as part of monthly multidisciplinary reviews involving the consultants and dietitians. Patient records we looked at showed staff appropriately recorded NEWS2 scores and included risk assessments for VTE, pressure ulcers, nutritional needs and risk of falls.

People who use the service told us the environment was safe, the design and condition of the rooms were good and met their needs. They said that the hospital areas and inpatient rooms were clean and that the equipment looked new.

The preoperative assessment area, ward and theatre areas were visibly clean, well maintained and free from clutter. Equipment was visibly clean and well maintained. Staff told us that all items of equipment were readily available and any faulty equipment was repaired or replaced in a timely manner. We observed documents that showed the service recorded and monitored when equipment had been serviced and repaired. The service provided evidence of staff training in the use of clinical equipment and non-clinical equipment.

Most staff told us they had no concerns regarding the building or environment. However, some staff told us that faults with the emergency bleep system and limited car parking onsite were areas that could be improved. The service had an alternative emergency bleep system in place until new equipment was available from January 2025. Staff told us this temporary system was working well and managers had recorded this risk appropriately on the hospital risk register.

The service had taken actions to reduce the impact of limited parking onsite. Staff informed patients of this issue prior to appointments and staff had access to another car park with free transport to the hospital. We observed a plan for a new car park that was part of the site development plan. The plan also included more storage space in the theatre sterile services unit (TSSU). The risk associated with the lack of storage space had been added to the hospital risk register and the service had an appropriate action plan in place. The service had employed an instrument coordinator for oversight and assurance that the area was being managed safely, there were daily cleaning schedules and deep cleaning every 6 months.

Staff carried out daily safety checks of specialist equipment. Emergency resuscitation equipment was available in all the areas we inspected and we saw that daily and weekly equipment check logs were complete and up to date in those areas. All the emergency resuscitation trolleys we saw were tagged to minimise the risk that items could be tampered with. Resuscitation trolley audits over the past three months showed resuscitation trolley compliance was 100%, indicating full staff compliance in maintaining resuscitation equipment.

The maintenance lead was located on site and was responsible for managing facilities and equipment. We observed up to date risk assessments and associated action plans. This included fire safety, ventilation, TSSU, legionella flushing of water outlets and environmental risk assessments including theatre and wards.

We looked at the hospital risk register and it showed that environmental risks were recorded, reviewed had had actions in place to mitigate the risk. This included the wheelchair accessible toilet which due to its size might make if difficult for some people to comfortably manoeuvre. Managers had taken action to modify the room with handrails and lowering bathroom fixtures.

The service had a business continuity management plan in place for the prevention and management of unplanned and emergency situations. This plan had been followed successfully when the emergency bleep equipment had become faulty.

There were arrangements in place for the handling, storage, and disposal of clinical waste, including sharps. The service complied fully with the Control of Substances Hazardous to Health (COSHH) practices.

People who use the service told us there were enough staff during and after their procedures and they provided safe care and treatment. They spoke positively about the way staff communicated and interacted with them and told us staff responded quickly when they requested assistance.

We saw that staff were available throughout the day to respond to patients in a timely manner. We observed that staff delivered positive interactions with patients and worked efficiently together. We observed an anaesthetist stay with a patient in the recovery area based on need and 2 nurses recovering patients at all times.

During the assessment we saw from the staffing rota and our observation that staffing in theatre and on the ward was sufficient and safe. Staffing levels were in line with the Association for Perioperative Practice (AfPP) and were based on the `safer staffing' acuity tool. This meant staffing levels could be adjusted daily according to the number of patients and their needs.

The ward and theatre managers carried out daily staff monitoring and escalated staffing shortfalls as part of the daily hospital-wide and departmental huddles.

The vacancy rate for clinical staff (including surgery and outpatients) was 3.3% as of November 2024. Gaps in staffing levels were addressed mainly through use of bank staff to ensure that patients were safe and received the right level of care. The service monitored its agency and bank usage across the hospital. Data for the previous 8 months showed that bank usage was 12% and agency usage was 0.6%.

The service had enough medical staff to keep patients safe. Surgical procedures were carried out by a team of consultant surgeons and anaesthetists who were mainly employed by other organisations (usually in the NHS) in substantive posts and had practising privileges with the Beaumont Hospital. The process for review of practising privileges ensured consultants were practising within their scope of practise. Patients were reviewed by a consultant daily.

The service had a rota for RMO's to provide medical cover on the wards. During their shift, one RMO was based at the hospital 24 hours per day with further cover from at least three RMOs. Managers told us that all RMO's were familiar with the hospital and the clinical needs of patients.

The vacancy rate for non-clinical staff was higher (5.45%) than for clinical staff. This included vacancies for medical secretaries which had negatively affected capacity and led to delays in clinical correspondence. We observed clinical governance committee (CGC) meeting minutes from November 2024 that showed staffing issues concerning medical secretaries had been added to the risk register.

Staff received and kept up-to-date with their mandatory training. The mandatory training was comprehensive and met the needs of people who use the service and staff. There was a practice based educator who monitored compliance and supported staff with their training needs. Compliance with mandatory training was high. Data provided by the service dated December 2024 showed that 99% of all staff had completed mandatory training, in line with the provider's training completion target of 95%.

Data provided showed that 100% of all required staff had completed advanced life support (ALS) and immediate life support (ILS). Basic life support (BLS) training had been completed by 98% of all required staff.

All staff, including bank and agency staff received a full induction tailored to their role before they started work. Staff told us they received annual appraisals and the service monitored compliance. The compliance with annual appraisals for all staff groups was 97%. The service recorded and monitored when doctors and consultants working under practicing privileges had completed appraisals with their own organisations (usually an NHS trust).

The provider's recruitment policy outlined the recruitment and fit and proper person checks carried out for new staff, including for agency staff. We looked at a selection of staff recruitment files. These showed appropriate recruitment and pre-employment checks had been carried out.

People who use the service told us the premises and equipment were visibly clean and tidy and they did not have any concerns relating to the cleanliness of the environment and equipment.

The service had infection prevention and control (IPC) policies which guided staff on processes and practices such as hand hygiene, cleaning of the perioperative environment and isolation of people with known or suspected infections. Staff we spoke with told us they were aware of these policies and knew how to access them.

The service had an IPC lead who oversaw infection control processes and provided support for staff.

Staff told us they had received training in IPC and hand hygiene. Data provided by the service for December 2024 showed that 99% of all clinical staff and 100% of non-clinical staff had completed mandatory IPC training.

Staff understood the processes for managing risks related to SSI’s. Staff told us they routinely monitored and escalated any suspected SSI’s to the managers and to the medical staff so people could receive appropriate treatment and transfer to hospital if required.

The service undertook regular IPC audits to monitor compliance with hand hygiene and general IPC principles including the environment and equipment. Audit results for the ward and theatre areas showed compliance for hand hygiene was consistently 100% from December 2023 to November 2024. Audit results for general IPC principles for the same time period ranged from 96% to 98% and met the providers target of 95%.

The preoperative assessment area, ward and theatres were visibly clean and had suitable furnishings which were clean and well-maintained. Cleaning schedules were in place with clearly defined roles and responsibilities for cleaning the environment and cleaning and decontaminating equipment.

People who use the service were screened for infections such as Methicillin-resistant Staphylococcus Aureus (MRSA) and the service had isolation rooms to support the management of cross infection risks. There had been no cases of MRSA or Clostridium difficile (C.diff) infections at the hospital for the previous 12 months.

There were enough hand wash sinks and hand gels. People who use the service and visitors were encouraged to wash their hands. We observed staff following hand hygiene and 'bare below the elbow' guidance appropriately. Staff were observed wearing personal protective equipment, such as gloves and aprons, while delivering care. Gowning procedures were adhered to in the theatre areas.

Clean linen was appropriately stored and segregated in dedicated storage areas.

The service conducted surveillance of SSI’s and each incident was reported and investigated by the patient safety incident response group (PSIRG) to look for improvements. Data provided by the service showed that 5 SSI’s had been reported between December 2023 and November 2024. There were no recurring themes or trends that could attribute to the infection rates. A further SSI was reported in December 2024 and data provided by the service showed this had been graded as moderate harm and would be discussed at PSIRG as per process.

Staff followed national best practice to check patients had the correct medicines when they were admitted to the hospital. Pharmacy advice and input into anaesthetic and perioperative assessment was available `ad hoc', on request. Medicines administration records were clearly presented and up to date. On discharge people were given verbal and written information about what to do and whom to contact if for example, they were unsure how to take their medicines or manage any side-effects. Discharge letters were sent electronically to people's GPs so that records could be kept up to date.

Following several incidents related to discharge medicines the hospital was focused on improving learning from incidents to improve practice. Additionally, a joint quality improvement project was underway with a sister hospital to produce medicines counselling `flash cards' to support improvements in nurse led discharge medicines conversations with patients. The hospital pharmacy had also relaunched the hospital medicines management training and medicines competency lists for all registered ward staff.

The provider had effective systems to manage and respond to safety alerts and medicine recalls. However, we found a delay in investigating one medicines related incident due to staff absence, the hospital had identified the need to `establish a robust procedure for reallocating investigations in such circumstances.' The incident investigation found a lack of guidance for prescribers about the management of delirium. We also found a lack of guidance about the management of severe anxiety and agitation.

There was a programme of regular medicines audits to help ensure hospital policy was followed in practice. Prescription stationery was securely managed. Medicines including controlled drugs were stored safely and securely at appropriate temperatures.