Chaucer Hospital

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• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

This means we looked for evidence that people were protected from abuse and avoidable harm. We assessed all quality statements. At our last assessment we rated this key question good. At this assessment the rating has remained good.

There was a culture of safety and improvement and learning from incidents was evident. Staff described an open culture where they felt able to raise concerns. This was an improvement from our previous assessment. Staff had training in key skills and managed safety well. There was a strong understanding of safeguarding and how to take appropriate action. The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. There were processes to ensure the service had enough staff with the right training, skills and qualifications to keep patients safe 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.

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 recognised incidents and near misses and reported them appropriately. Staff told us they were encouraged to report concerns and safety events. Staff felt confident to challenge clinical decisions and escalate. They told us the director of clinical services and senior manager on-call were always supportive. The hospital philosophy was ‘safety first’.

Leaders investigated incidents and shared lessons learned with the whole team and the wider service. Staff discussed themes, trends, and learning from incidents as an agenda item in all meetings. Leaders encouraged staff to reflect on every incident and consider the learning outcomes.

Staff shared examples of learning from incidents and actions to drive improvements. For example, bespoke training to improve patient outcomes and colour coding of theatre lists to highlight operational priority. In addition, staff told us they were well supported following an incident or difficult shift and gave examples of when leaders had attended the unit out-of-hours to provide face-to-face support.

Staff received training in human factors, and we saw that human factors were considered during the morning communication meeting and safety huddles. For example, staff breaks were prioritised. Human factors refer to environmental, organisational and job factors, and human and individual characteristics, which influence behaviour at work in a way which can affect health and safety.

The service had safety champions, and staff knew who to speak to if they had safety concerns. This showed a commitment to a proactive and positive safety culture.

We saw 353 incidents were reported between July 2024 and June 2025. Leaders graded incidents according to level of harm, investigated all cases of moderate and severe harm and shared leaning. They ensured actions from patient safety alerts were implemented. We saw families were involved in investigations and staff apologised when things went wrong and gave patients honest information and suitable support.

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.

Leaders described positive relationships with partners which included the Integrated Care Board (ICB) and local NHS trust. The service had a service level agreement with the local NHS trust and transferred patients in the event of an emergency. Staff had access to the escalation protocol for a deteriorating patient. This clearly outlined the response required in dealing with different levels of abnormal physiological measurements and observations.

The service’s referral and admission processes ensured that all essential information about the patient was received to determine if the patient’s needs could safely be met. Staff followed policies and procedures and worked together to provide safe and effective care throughout the patient’s journey.

We saw effective communication strategies embedded in daily practice, including the use of team briefings and debriefings. We observed effective application of the World Health organisation (WHO) Surgical Safety Checklist and Five Steps to Safer Surgery and evidence showed this was consistently and accurately applied.

Theatre staff used a specific template to support information sharing during their morning safety huddle. This included key information such as equipment checks, advanced life support practitioner, staffing and consumables. Staff used a standard template to handover patient care and recorded all details. This included transfers from theatre to the ward and any transfers to the local NHS trust.

Staff discussed discharge planning with patients at the pre-assessment appointment so that effective plans were in place to meet patient needs when discharged. We saw effective discharge plans in patients’ notes. The hospital sent electronic discharge letters to patients’ GPs with details of their treatment provided, medicines and follow up arrangements.

Patients told us the hospital managed their care well from referral to discharge and were told what to expect in terms of their recovery. The hospital received between 537and 578 monthly survey responses, and 99% of patients felt adequately prepared for treatment because of the pre-admission appointment. Patients also commented on the smooth transition from theatre to recovery and back to the ward.

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.

The hospital’s executive director was responsible for safeguarding, and the director of clinical services (DCS) was the safeguarding lead for the hospital. Staff described the DCS as very supportive and available to support with any safeguarding concerns.

The hospital had a clear safeguarding policy and pathway which was up-to-date and reflected national guidance. This was accessible to staff through the hospital intranet. Safeguarding posters were displayed in pre-operative assessment, theatres and ward areas. Staff knew how to access safeguarding policies and procedures, and how to escalate safeguarding matters.

Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Leaders ensured staff received mandatory training in safeguarding relevant to their role. At the time of our assessment 100% of staff were trained to level 2 and level 3 safeguarding adults and 98% were trained in safeguarding children level 2.

Staff could give examples of how to protect patients at risk of, or suffering, significant harm and understood the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS) and had completed training for both. The MCA is designed to protect individuals aged 16 and over who may lack the mental capacity to make decisions regarding their care and treatment. DoLS is the legal right to remove a person’s freedom of movement to keep them safe and /or ensure they get the right treatment.

Staff told us they occasionally had patients who lacked capacity and knew how to care for patients living with dementia. They shared several examples of how they had identified a safeguarding concern through professional curiosity, made an appropriate safeguarding referral and effectively worked with the multidisciplinary team and agencies to keep the patient safe.

Staff followed safe procedures for family and friends visiting the ward. Access to the wards was by restricted access

The evidence showed a good standard. The service worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

The hospital did not admit children or young people under the age of 18 years. There was clear criterion for adult patients having minor, intermediate and major surgical procedures under general anaesthesia or anaesthesia led sedation. Patients with complex medical needs and bariatric (a high body mass index) patients were not accepted, as the service could not meet their needs.

Staff had clear guidance on what needed to be referred to the Decision to Admit Review Team (DTAR). This team held multidisciplinary weekly meetings to determine suitability for surgery at the hospital. They decided to admit or decline patients and escalated clinical concerns about patients’ suitability to the consultant anaesthetist and consultant surgeon.

Patients accepted for elective surgery had a pre-assessment to ensure they met the hospital inclusion criteria. This assessment was carried out by a registered nurse and provided an opportunity to make sure patients were fully informed about the surgical procedure and post-operative recovery period. We saw evidence that the assessment included a plan and booking of additional support as needed. For example, advocacy and translators.

The hospital received between 537 and 578 monthly survey responses from patients. We reviewed results from January 2025 to June 2025 which showed between 99% of patients felt adequately prepared for surgery because of their pre-assessment and information, and 100% felt confident their consultant would deliver appropriate care.

The theatre briefing involved all members of staff and ‘sign-ins’ were carried out correctly. All required staff members were present and there was full patient involvement. This was in line with local policy. Theatre staff performed an extra check before the ‘time out’ stage of the WHO checklist. They re-checked the patient’s wrist band against the consent form before the patient was prepared and draped for surgery

Staff completed an SBARD (Situation-Background-Assessment-Recommendation-Decision) document when a deteriorating patient was escalated. This was completed to ensure essential information was communicated and supported a timely response.

The service kept a sepsis recognition and response policy which was up to date. This outlined the actions required for patients with suspected or confirmed sepsis.

The evidence now showed a good standard. The service had improved from our previous inspection and detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The design of the environment followed national guidance. The hospital had suitable facilities to meet the needs of patients having elective surgery. There were 2 main operating theatres, with 2 anaesthetic rooms and 3 recovery bays. There was a treatment room in outpatients for minor procedures. Each of the designated areas had the required equipment. Staff kept a logbook with each anaesthetic machine to record the daily pre-session check. We saw they had been completed, as recommended by the Association of Anaesthetists of Great Britain and Ireland.

The hospital was secure, and the service controlled access to critical and restricted areas using swipe card access for staff. There was 24-hour CCTV coverage around the building which could be viewed at main reception. Main reception was covered by dedicated staff from 7am to 10pm (5pm on weekends) and porters were on-site 24/7 with walkie talkies for immediate communication.

Staff told us they now had enough suitable equipment to perform their role, and 1 consultant gave an example of how they requested a piece of equipment which the hospital provided.

The service had effective processes for the management of accountable items, including swabs, instruments, and sharps. We observed a theatre list and noted sharps safety protocols were strictly followed, with safe handling and disposal practices observed throughout. Surgical instrument trays were traceable, with tracking systems to ensure full accountability from decontamination to point of use.

The service had resuscitation trolleys on the ward and in theatres. We saw staff checked these daily and replaced any used or out-of-date equipment or consumables. Staff carried out daily safety checks of specialist equipment and ensured servicing was up to date. Leaders monitored compliance of safety checks of electrical equipment. They ensured medical devices had planned service checks within the required time frame and compliance was 100%.

The hospital completed regular maintenance, servicing and testing of water systems to minimise the risk of Legionella bacteria. Staff followed the policy for Legionella and Pseudomonas, and a site water risk assessment was completed and regularly reviewed. This was in line with national guidance.

The service displayed hazardous waste warning signage when needed. Staff stored Control of Substances Hazardous to Health (COSHH) products in locked cupboards in a designated storage area in the locked sluice.

Staff separated clinical waste and used the correct bins. They stored waste in locked bins while waiting for removal. Staff disposed of clinical waste safely. Sharps bins were labelled correctly and not over-filled.

The service organised storerooms with clear labelling, logical layout, and safe, accessible storage of consumables and equipment. Staff labelled consumables with red dots to highlight which consumables should be used immediately to reduce waste.

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.

The service had enough nursing and support staff to keep patients safe. Managers ensured the ward and theatres had enough skilled staff to provide appropriate care and treatment on site. The hospital mainly undertook elective surgery, which meant there was clear guidance for staffing levels.

The hospital followed the Association for Perioperative Practice (AfPP) guidelines. This included a minimum theatre staffing levels of 2 scrub practitioners, 1 circulating staff member, 1 registered anaesthetic practitioner and 1 recovery practitioner for each theatre list. We saw the ward and theatres had the correct number of staff when we visited.

The theatre manager planned rotas 1 month in advance with theatre leads. They told us they focused on skill mix, safe staffing, and avoiding over or under-staffing. Staff were encouraged to use ‘Stop-the-Line’ to protect safety. Stop-the-Line is a patient safety initiative that supports staff to halt a procedure such as surgery due to safety concerns. Managers told us they cancelled theatre lists if staffing gaps could not be appropriately filled.

We saw daily safety huddles and the morning communication meeting included any staffing short falls and considered staff roles and experience for all clinical areas. The director of clinical services could redeploy staff or stop activity if patient safety was at risk. Leaders told us they had control over workload and scheduling because surgery was elective, and activity would be paused if safety was compromised.

Leaders told us it was very rare for the service to use agency staff. Managers used a regular pool of bank staff to help ensure they were familiar with the service. They ensured all bank (and agency) staff had completed mandatory training, had a full induction and understood the service. Bank staff were recruited through the same process as substantive staff to ensure they had the right knowledge and skills to maintain patients’ safety.

Leaders monitored vacancy and sickness rates. The service had 1 theatre practitioner vacancy when we visited. They employed 1 surgical first assistant as part of their regular bank staff and provided evidence of their registration and suitable qualification.

The service had enough medical staff to keep patients safe. All patients were admitted under the care of a named consultant. At the time of the assessment there were 144 consultants practising under practising privileges. Practising privileges is a term used when doctors have been granted the right to practise in an independent hospital. Most of the consultants practising in the hospital also worked within the NHS.

The hospital expected consultants to visit their patients daily after surgery. They were also expected to be on-site (within 45 minutes) to review post-operative deteriorating patients or have agreed cover. However, we did not see evidence that this was monitored.

The policy for practising privileges outlined that consultants should contact the NHS trust for daily updates when patients had been transferred although staff advised they never received updates for transferred patients.

Leaders provided mandatory training and ensured staff completed it. Mandatory training was comprehensive and included but was not limited to adult basic life support, information governance, fire safety and dementia awareness. Training compliance was between 99% and 100%, and mostly 100% for all nursing, medical, allied health care professionals and non-clinical staff. Leaders told us key staff completed training in advanced life support (ALS), and an ALS practitioner was available on all shifts.

The service maintained competency frameworks and skills checklists for each surgical specialty. The theatre manager or senior clinicians signed off clinical skills. Oversight of staff skills was maintained with a skill matrix that was monitored and updated annually. The theatre manager allocated theatre staff based on competencies and cross-referenced with the skills matrix. Leaders also told us staff were encouraged to escalate concerns if allocated beyond their competence.

The service allocated mentors and supervisors to oversee staff practice in new specialties. The theatre and clinical governance committee regularly reviewed competencies and allocations.

Leaders provided opportunities for staff development, and we saw evidence that 100% of staff (nursing and medical) had an appraisal within the previous 12 months. Staff we spoke with told us appraisals were meaningful, and staff development was supported. For example, a health care assistant had recently been supported to complete their training to become a nursing associate.

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.

The service had an infection prevention and control (IPC) lead nurse. They were supported by IPC champions for each clinical area. Clinical staff were trained in IPC level 1 and compliance was 100%. Non-clinical staff were trained in IPC level 2, compliance was 97%. Staff also received mandatory training in aseptic non-touch technique, and compliance was 100%.

The hospital had an up-to-date policy to guide staff on infection prevention and control which reflected national guidance. Leaders monitored compliance to the policy and effectiveness of training through regular IPC and hand hygiene audits, which were consistently 100%. The IPC lead told us the hospital would develop an action plan if results showed non-compliance.

Department audit leads collected data and discussed results in key meetings. Any escalations were fed into the hospital clinical governance committee and discussed at corporate clinical governance committee if required.

All areas were visibly clean and had suitable furnishings which were clean and well maintained. Staff cleaned equipment after contact with patients. Cleaning records were up-to-date and showed all areas were cleaned regularly and met required standards for the last 3 months.

Bathrooms and toilets were visibly clean and included laminated posters explaining hand washing technique. Privacy curtains were clean and labelled with their replacement date. We saw housekeepers going about their duties and they were familiar with the hospital and cleaning polices.

The service provided dedicated bags in the theatre changing area for theatre staff to store their outdoor and theatre shoes. This ensured floors remained free from dirt and clutter and contributed to the overall cleanliness of the department.

All staff were bare-below-the elbow and followed IPC principles. We observed staff washing their hands and decontaminating them with antibacterial hand gel and wearing personal protective equipment (PPE) when indicated.

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 was registered with the Home Office and held a controlled drugs (CD) license as required and in line with the Misuse of Drug Act 1971. We looked at the CD register and a sample of CDs which showed all were stored securely and any CD administered had 2 signatures recorded as required. Stock matched the register, and any wasted CDs were recorded.

The service had an up-to-date policy for medicines management and code of practice for CDs. There was a patient information leaflet to support understanding regarding medicines advice around the time of surgery.

The hospital completed medicines and CD audits every quarter. Audits focused on the safety, security and safe administration of medicines. We saw results were 97% for safe medicine management for March and May 2025. The CD audit was completed quarterly by the department audit lead and pharmacist. Results were 97% for March and May 2025. The service discussed audit results in unit meetings and local medicine management meetings. Any concerns were escalated to the hospital clinical governance meetings.

The pharmacy team visited the ward daily to review inpatient medicines and organise take home medicines for patients due to be discharged. They reviewed patient’s own medicines on admission and checked stocks of medicines twice weekly. Staff discussed patients on high-risk medicines, admissions and discharges and agreed a plan of action. Staff told us they did not experience problems accessing medicines.

Medicines were kept in a clinical room with keypad access and cupboards in the room were locked. Keys for those cupboards were kept in a coded key safe in line with standards for good medicines management.

Staff maintained a daily record of fridge, freezers, warming cabinet and room temperatures where medicines were stored. Leaders ensured that only registered nursing staff had access to medicines. Medicines were stored securely in a dedicated medicines room, which could be accessed only by registered nurses for the purpose of dispensing medication to individual patients.

Staff reviewed each patient’s medicines regularly and provided advice to patients and carers about their medicines. The hospital’s monthly survey responses showed between 94% and 96% of patients felt they were advised about potential side effects to look for. We reviewed 3 medicine charts, and all were completed in full, signed and dated. Patient data such as weight was recorded to calculate medicines and allergies were recorded.