Chaucer 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 meant we looked for evidence that people were protected from abuse and avoidable harm. We assessed all quality statements.

We looked for evidence that safety was a priority for everyone, and leaders embedded a culture of openness and collaboration. We checked that people were safe and protected from bullying, harassment, avoidable harm, neglect, abuse and discrimination.

At our last assessment we rated this key question good. At this assessment, the rating remained good. This meant people were safe and protected from avoidable harm.

We found that the service had a culture of learning, where staff felt able to raise concerns and managers investigated and shared learnings from incidents. Staff understood how to identify, and report safeguarding concerns. The care environment was in good condition and staff had sufficient equipment. 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. Staff managed medicines well.

The hospital reported significantly higher patient transfer out rates, when compared to similar hospitals. However, this on its own was not considered an indicator of poor care, and the service shared learning and completed thematic reviews to understand this performance and identify any opportunities for improvement.

The service had clear admission criteria, had strengthened pre-assessment processes and completed safety checks in theatre.

The hospital had a service level agreement with the local NHS trust and transferred patients in the event of an emergency.

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. Leaders encouraged staff to report concerns and safety events, and staff felt confident to challenge clinical decisions and escalate when needed. Staff told us that managers on-call were always supportive. Following a significant incident, staff completed debrief forms and met to discuss their initial learning and reflections. We saw an example of a staff debrief following the transfer of 2 patients to the local NHS trust because of drops in sodium levels following surgery. Staff and leaders found this promoted wellbeing across the teams.

Leaders investigated incidents and shared lessons learned with individual teams and the wider services. Staff discussed themes, trends, and learning from incidents as an agenda item in meetings. The service learned from an incident where a critical consumable needed for mesh fixation in surgery was missing, despite checks by the supplies and theatre teams. The procedure was cancelled as a result. In response, refresher training was delivered to reinforce the process for verifying all critical items.

Leaders encouraged staff to reflect on incidents and consider the learning outcomes. The service had an up-to-date incident management policy that staff accessed through the hospital intranet.

Staff shared examples of learning from incidents, and the actions taken to drive improvements. Lessons learned from safety incidents resulted in changes that improved care for others. An example involved a patient whose full medical history had not been recorded during pre-assessment. Staff learnt that hospital notes must be reviewed alongside the pre-assessment to ensure all relevant information is included. We saw this learning had been shared with staff.

The service had appointed 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.

The hospital reported 214 incidents between June and November 2025, of which 41 related specifically to the surgery service. Leaders graded incidents according to the level of harm, although the data provided did not allow us to determine the harm levels for those incidents relating to the surgery service solely. During this period the most frequently occurring themes were same-day surgery cancellations, communication issues, equipment failure or unavailability and surgical complications.

Leaders investigated either locally at department level, or where incidents indicated more significant actual or potential harm, through enhanced learning responses. They shared learning from investigations with staff, to support improvement in practice and patient safety.

During the same timeframe the Patient Safety Incident Response Group (PSIRG) commissioned 1 Patient Safety Incident Investigation (PSII) following a patient’s unexpected death. The PSIRG is the organisation’s multidisciplinary leadership group responsible for reviewing patient safety information, determining which incidents require formal investigation, and ensuring that appropriate learning responses are undertaken. A PSII is a formal, systems‑based investigation commissioned for incidents that may have caused significant harm or where important safety risks are identified, with the purpose of understanding how and why the incident occurred and identifying actions to reduce future risk. Leaders implemented actions from patient safety alerts.

Staff and leaders we spoke with demonstrated an understanding of duty of candour requirements, and we saw these were carried out appropriately. The duty of candour is a legal requirement for providers to be open and honest with people when something goes wrong with their care, including explaining what happened, apologising, and outlining what will be done to prevent it happening again. The service had a duty of candour policy and staff followed this process.

Between July and November 2025, the hospital reported 20 incidents that resulted in duty of candour. The provider told us these included 18 notifiable incidents and 2 professional safety incidents, each triggering a formal duty of candour response. The provider shared examples of letters sent to patients, showing how they applied duty of candour by offering an early apology and committing to share investigation outcomes when available.

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.

Staff followed referral and admission processes that collected essential information about patients to determine whether their needs could be safely met. Staff referenced policies and procedures and worked together to provide safe and effective care. The service had strengthened pre-assessment processes to ensure staff captured all necessary information consistently.

The service did not admit children or young people under the age of 18 and had clear criteria for accepting adult patients undergoing minor, intermediate and major surgical procedures under general anaesthesia or anaesthesia-led sedation. Patients with complex medical needs as well as bariatric patients with a high body mass index), were not accepted, as the service could not safely meet their needs.

The Resident Medical Officer (RMO) reviewed all pre‑operative investigation results, including routine blood tests and electrocardiograms (ECGs). Any abnormalities or concerns identified during this review were escalated promptly to the anaesthetist for further evaluation and decision‑making.

Staff had access to a comprehensive pre-assessment policy that provided guidance on when people should be referred for further review. Staff used this guidance to identify patients who needed to be escalated to the Decision to Admit Review Team (DTAR). The DTAR consisted of a multidisciplinary team that met weekly to assess people’s suitability for surgery at the hospital. They decided whether to admit or decline patients, based on risk and clinical criteria, and escalated concerns about patients’ suitability to the consultant anaesthetist and consultant surgeon.

Staff discussed discharge planning with patients at their pre-assessment appointment so that appropriate arrangements could be made to meet their needs on discharge. Staff documented effective discharge plans in patients’ notes. The service sent electronic discharge letters to patients’ GPs outlining the treatment provided, medicines prescribed and follow-up arrangements.

Theatre staff used a specific template to support information sharing during their morning safety huddle. This included information such as equipment checks, allocation of advanced life support practitioner, staffing and consumables. Staff also used a standard template to handover patient care and recorded all necessary information. This included transfers from theatre to the ward and any transfers to the local NHS trust. Records showed that staff consistently followed these processes and kept patients safe.

Theatre staff demonstrated effective communication strategies. Staff applied the World Health Organisation (WHO) Surgical Safety Checklist which standardises key safety checks at critical stages of surgery and the Five Steps to Safer Surgery, which built on the WHO checklist by adding briefing and debriefing, which widened the focus beyond individual cases, to the whole list. Staff and leaders audited compliance to ensure these were always applied. Audits found 100% compliance in the process for Major Surgery between November 2024 and October 2025.

On the ward, nursing staff completed a series of paper based risk assessments in line with organisational policy and national best practice. These included assessments for falls risk, moving and handling, and pressure ulcer prevention. Nutritional status was evaluated using the Malnutrition Universal Screening Tool (MUST), alongside completion of the Clinical Frailty Score, delirium screening, and skin integrity assessment. Leaders monitored compliance through audits. The service achieved 100% compliance for falls and pressure ulcer risk assessments between August and November 2025.

Staff supported physiological monitoring and early detection of deterioration through regular National Early Warning Score 2 (NEWS2) observations. They carried out sepsis screening where clinically appropriate, ensuring that early indicators of infection or deterioration were promptly escalated and managed.

Staff had access to the escalation protocol for deteriorating patients, which set out how to respond to different physiological measurements and observations. They also had access to an up-to-date sepsis recognition and response policy, which outlined the actions required for patients with suspected or confirmed sepsis. Sepsis recognition training was 100% in December 2025.Ward staff completed a Situation-Background-Assessment-Recommendation-Decision (SBARD) document to ensure essential information was communicated to support a timely response in the event of a patient’s condition deteriorating. Patient records showed this process was effective and information was clearly communicated and acted upon by medical staff.

The hospital had a service level agreement with the local NHS trust and transferred patients in the event of an emergency. The service reported transfer‑out activity as a rate per 100 amended discharges. From June to October 2025, the transfer‑out rate ranged from 0.2 to 0.7 per 100 amended discharges, with an average of 0.4 across the period. These rates were higher in most months than those seen in similar hospitals within the group. The service reviewed this performance, completed thematic analyses, and shared learning to identify any opportunities for improvement. The rate per 100 amended discharges generally means a measurement of how often a specific event (such as a readmission, infection, or error) occurs, normalised against every 100 patient discharges. This allows for comparing performance across hospitals of different sizes.

Staff carried out venous thromboembolism (VTE) risk assessments at pre‑admission, on admission and following surgery, in line with national requirements. We observed VTE risk assessments being recorded in theatre. VTE Prevention training was 100% in December 2025. However, compliance for VTE risk assessment completion between August and November 2025 was below the service’s target of 90%, and leaders developed an action plan to address this.

VTE includes deep vein thrombosis and pulmonary embolism (PE). A PE occurs when a blood clot travels to the lungs and can be life‑threatening if not diagnosed and treated promptly. The standard diagnostic test for confirming or excluding a suspected PE is a Computerised Tomography Pulmonary Angiography (CTPA) scan.

The hospital was able to perform a CTPA scan within normal hospital hours. However, staff told us that CTPA was not available out of hours, and patients requiring urgent imaging for suspected PE were therefore transferred to the local NHS trust.

The service provided audit results for the National Safety Standards for Invasive Procedures (NatSIPPs) for the period November 2024 to September 2025, which reported 100% compliance. NatSIPPs set out nationally agreed safety processes for invasive procedures, including key stop moments such as verification and time out, designed to reduce error and support effective teamworking. We noted that the audit template used was based on the original NatSIPPs standards, indicating the service may not yet have adopted the updated NatSIPPs 2 standards introduced in 2023.

The theatre team demonstrated good adherence to sequential safety steps following Prep, Stop, Block safety steps. Audit results from May, August, and November 2025 showed a 100% compliance with this process. Prep–Stop–Block is a national safety protocol for regional anaesthesia that requires staff to complete all preparation, pause together to confirm the correct side immediately before needle insertion, and then proceed directly with the block to prevent wrong‑site errors. This was in line with The Safe Anaesthesia Liaison Group (SALG) and the Regional Anaesthesia UK (RA-UK) national Standardised Operating Procedure (SOP) to prevent wrong side block.

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. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm, and neglect. Staff shared concerns quickly and appropriately.

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

The hospital had a nominated safeguarding lead, trained to level 4 in both adult and child safeguarding, who staff described as highly supportive, approachable, and consistently available. Their role included supporting staff, ensuring appropriate escalation, and liaising directly with the Local Authority Safeguarding Team when needed.

Staff gave examples of how to identify patients at risk of, or suffering, significant harm. They understood the Mental Capacity Act (MCA) 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 capacity to make decisions regarding their care and treatment. DoLS provides the legal framework for restricting a person’s freedom of movement when necessary to keep them safe or ensure they receive appropriate treatment.

If patients lacked capacity, staff knew how to care for patients living with cognitive conditions. Staff told us they understood how to provide appropriate care and support for patients who lacked capacity, including those living with cognitive conditions. They shared an example from an outpatient appointment where staff recognised a patient was struggling to process information about a minor procedure. In line with the Mental Capacity Act (MCA), they completed a capacity assessment, which confirmed the patient could not make this specific decision. This ensured the patient received the right support and that decisions were made safely and in their best interests.

Staff shared a further example of how they supported a patient who had a previous distressing reaction after the operation. Staff ensured safety, privacy, and a calming environment, gave reassurance on waking, extended recovery time and completed documentation to support ongoing emotional monitoring.

Staff had access to an up-to-date safeguarding policy and pathway which reflected national guidance through the hospital intranet. The service displayed safeguarding posters in pre‑operative assessment areas, theatres, and wards. Staff knew how to access safeguarding policies and procedures, and how to escalate safeguarding concerns.

Staff completed PREVENT (Protecting People at Risk of Radicalisation) training, and compliance in December 2025 was 100%.

Staff followed safe procedures for family and friends visiting the ward. They controlled access to the wards using keycard entry.

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 allowed people to do the things that mattered to them.

Pre-assessment staff carried out face-to face or telephone appointments to determine whether patients met the hospital’s inclusion criteria and were suitable to proceed with surgery. These assessments provided an opportunity for staff to ensure patients were fully informed about their planned surgical procedure and expected post-operative recovery period. Pre-assessment staff produced a plan of initial care and booked any additional support identified. For example, advocacy and translators.

Staff involved patients in completing safety checks when collecting them from the ward and again on arrival in the anaesthetic room. They introduced themselves, explained their roles, and checked the patient’s name, date of birth, allergies, expected surgery, surgical site and consent.

Patients told us the service managed their care well from referral to discharge, and that staff told them what to expect during their recovery. Between September and November 2025, 99% of patients reported feeling adequately prepared for their treatment because of their pre-admission appointment.

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 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. The design of the theatre setting followed national guidance.

Theatres stored emergency equipment in the dedicated theatre emergency equipment area, which was visibly clean and tidy, with all equipment stored off the floor. We checked the emergency equipment and found all equipment had undergone electrical safety checks within the last 12 months. All consumables checked were within their expiry date. We reviewed records from October to December 2025 and found that staff checked these daily and monthly.

Staff carried out daily safety checks of specialist equipment and ensured servicing was up to date. Managers monitored compliance of safety checks of electrical equipment. They ensured medical devices had scheduled service checks and equipment had annual calibration testing. We checked 7 electrical items and found all to undergone electrical safety testing in the last 12 months.

Staff kept a logbook with each anaesthetic machine to record the daily pre-session safety checks in line with the Association of Anaesthetists of Great Britain and Ireland (AAGBI) guidelines. We found checks to be consistently recorded.

Staff kept the hospital secure and used swipe cards to control access to restricted areas. There was 24-hour CCTV coverage throughout the building which could be monitored from the main reception. The reception was staffed from 7am to 8pm (5pm on weekends), and porters were always on site.

The service had effective processes for the management of accountable items, including swabs, instruments, and sharps. We saw staff use boards in theatre to correctly record accountable items. Staff followed sharps safety protocols with safe handling and disposal practices. We checked 5 sharps bins and found these appropriately labelled and not over-filled. Surgical instrument trays were traceable, with tracking systems to ensure full accountability from decontamination to point of use.

The service had resuscitation trolleys in 5 locations across the hospital. Of these resuscitation trolleys, we inspected 2 in the ward and theatre environments and found staff checked these daily and replaced any used or out-of-date equipment or consumables. The service completed an annual health and safety risk assessment of the premises, which leaders most recently reviewed in August 2025.

The service had designated fire wardens, an established evacuation plan, and all fire exits were clear. Compliance with fire safety training was 100% in December 2025.

The service completed regular maintenance, servicing and testing of water systems to minimise the risk of Legionella bacteria. Staff followed the hospital 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. We found the theatre COSHH cupboard unlocked during our assessment, which staff told us was because a COSHH item had been required at the time. Staff separated clinical waste and stored it in locked bins while waiting for removal.

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.

Staff tested emergency bleeps daily and bleep-holders were required to call reception to confirm that they had received the message and that the bleep was functioning correctly.

The hospital had a generator and an uninterrupted power system (UPS) to support essential equipment in the event of a power failure. Emergency lighting systems were fully operational and there were no concerns regarding their availability or performance. Staff told us while key clinical and safety‑critical systems were protected, some non‑essential elements, such as general lighting, were not. The hospital recognised this as the highest‑rated risk on its risk register, with a score of 8 (medium). Leaders put suitable mitigations in place while awaiting the upgrade of the emergency lighting. Back‑up battery packs and torches were already available to staff to support them during a power failure. Leaders had a planned programme of works underway to upgrade lighting, including the replacement of selected LED panels which enhancing resilience across the site.

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. Staff worked together well to provide safe care that met people’s individual needs.

Managers made sure the wards, theatres and pre-assessment had enough skilled staff to provide appropriate care and treatment. The service followed guidance for the needed staffing levels. Managers followed the Association for Perioperative Practice (AfPP) guidelines when planning theatre staffing. This included minimum theatre staffing levels of 2 scrub practitioners, 1 circulating staff member, 1 registered anaesthetic practitioner and 1 recovery practitioner for each theatre list. The service had access to surgical care practitioners (SCPs), who are registered healthcare professionals who extend their scope of practice.

The theatre manager planned rotas 1 month in advance with theatre leads allocated for each session. Managers focused on skill mix, safe staffing, and avoided over or under-staffing. Leaders encouraged staff 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 cancelled theatre lists if staffing gaps could not be appropriately filled.

We saw daily safety huddles and the morning communication meetings included staffing shortfalls and considered staff roles and experience for all clinical areas. Leaders could redeploy staff or stop activity if patient safety was at risk.

Staff received training in sepsis, medicine management, and the use of monitoring tools such as the National Early Warning Score 2 (NEWS2). Staff completed a preceptorship programme when they commenced employment at the service, which included 3 weeks of observation across different specialities.

Managers used a regular pool of bank staff who were familiar with the service to reduce the use of agency staff. They recruited bank staff through the same process as substantive staff to ensure they had the right knowledge and skills to maintain patients’ safety. The service used agency ward staff for 12 hours overall between June and November 2025. Agency theatre staff were used for 34 hours over the same period, both were within the service compliance target. Managers made sure bank and agency staff completed mandatory training, had a full induction, and understood the service.

The service engaged consultants under practicing privileges, a formal agreement that permits self‑employed consultants to work within an independent hospital, enabling them to admit, treat, and manage patients while remaining responsible for their own clinical practice. The hospital maintains oversight of these privileges through governance checks such as credentialing, annual appraisal, scope‑of‑practice review, and ongoing performance monitoring to ensure safe, quality care. The service had 144 consultants practising under practising privileges in July 2025, 11 of these were connected doctors. A connected doctor is a doctor formally linked to an organisation (a designated body) and its Responsible Officer for the purposes of appraisal, revalidation, and governance.

The service had a Practicing Privileges policy which expected consultants to visit patients daily after surgery and to be able to attend the site within 45 minutes to review post‑operative patients who were deteriorating, or to have agreed cover in place. The policy also required consultants to contact the NHS trust for daily updates when patients were transferred. During our last assessment, staff told us that they did not receive these updates. At this assessment, we saw that the information was available. However, we were unable to determine how effectively leaders communicated this information to staff.

The service used resident medical officers (RMOs) to provide medical care to patients 24 hours a day, seven days a week. In independent hospitals, a resident medical officer (RMO) is a doctor who provides continuous on‑site medical cover, delivering first‑line assessment, routine and emergency care, supporting consultants, responding to deteriorating patients, and acting as the hospital’s immediate medical presence. At the time of the assessment the service had 2 RMO’s, who were knowledgeable about the surgeries undertaken by the service, and aware of the risks they needed to consider. They reported having positive working relationships with consultants, and the service had clear escalation processes that enabled them to raise any concerns promptly.

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 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 had competency frameworks and skills checklists for each surgical specialty. The theatre manager or senior clinicians signed off clinical skills. Managers maintained oversight of staff skills with a skill matrix that leaders monitored and updated annually. The theatre manager allocated theatre staff based on competencies and cross-referenced this with a skills matrix. Leaders encouraged staff to escalate concerns if managers allocated them beyond their competence.

Leaders 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. The provider funded additional learning and qualifications. Staff were paid during their training and had access to study days and work placements. A practice-based educator provided 1 to 1 support to each trainee. In December 2025, there were 26 examples of staff development across the hospital that were either ongoing or complete. These examples were at all staffing levels and included clinical and non-clinical progression. For example, health care assistants (HCAs) had been supported to become registered nurses and assistant practitioners, the Infection, Prevention, and Control (IPC) lead had completed a postgraduate certificate in infection, prevention and control. The quality and risk manager had completed the Institution of Occupational Safety and Health (IOSH) and National Examination Board in Occupational Safety and Health (NEBOSH) qualifications.

Staff told us they found appraisals meaningful and felt supported in their development. Appraisal compliance in December 2025 was 100%.

Leaders monitored vacancy and staff turnover rates. In December 2025, the service reported 2 clinical theatre vacancies which accounted for 16% of the full time equivalent (FTE) budget for the service. They reported no clinical nursing vacancies.

Turnover among clinical theatre staff was significantly higher than the overall hospital rate (39% compared with 13.8%). The provider did not supply any context or explanation for this increased turnover, and therefore we are unable to comment on the underlying reasons. We requested sickness rates as part of this assessment. However, the provider was unable to supply this data.

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 external agencies promptly.

The hospital had an infection prevention and control (IPC) lead nurse, supported by nominated IPC champions for each clinical area. Clinical staff were trained to IPC level 2, with 100% compliance in December 2025. Non-clinical staff were trained to IPC level 1, also with 100% compliance. Staff received mandatory training in aseptic non-touch technique, with compliance at 100%.

The hospital had an up-to-date IPC policy that reflected national guidance. Leaders monitored compliance with the policy and the effectiveness of staff training through regular IPC and hand hygiene audits. IPC audit compliance for ward and theatre settings averaged 92% between September and December 2025. Pre-assessment compliance was 100% for the same period. Hand hygiene audit compliance for ward, theatre and pre-assessment was also 100% for the same period.

Leaders developed action plans and recommendations when IPC performance was not at the levels needed. For example, dust was observed in wards around the lights above beds, door frames, around the sinks in rooms, and front of ward station. In response to this, leaders placed a greater emphasis on housekeeping staff to ensure the areas were visibly dust-free on daily inspection. Managers achieved this by introducing a higher level of recording in cleaning logs which included the allocation of specific tasks and areas to nominated staff. In theatres, the audit found several sharps bins that were overfilled. In response, leaders reminded clinical staff of the requirement to close sharps bins when they reach three‑quarters full. This reduced the risk of overfilling and needlestick injuries for staff. Managers shared this through team meetings, email updates, notice boards and visual prompts. During our assessment we observed 5 sharps bins in theatres, all labelled, in the semi-closed position and not overfilled.

Department audit leads collected IPC data and discussed results in key meetings. Leaders fed escalations into the hospital Clinical Governance Committee (CGC) and discussed at corporate clinical governance committees if needed.

Leaders and staff identified 4 suspected surgical site infections (SSIs) associated with hip and knee surgery between June and November 2025. Leaders monitored SSIs monthly and they formed part of the IPC performance data sets.

All areas were visibly clean and had suitable furnishings which were clean and well maintained. Staff cleaned equipment after contact with patients. Bathrooms and toilets were visibly clean and included laminated posters explaining hand washing technique. Privacy curtains were clean and labelled with their replacement date. Housekeepers were familiar with the hospital and cleaning polices.

Dedicated bags were available 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.

Staff were bare below the elbows and followed IPC principles. They washed their hands and decontaminated them with antibacterial hand gel. Staff wore personal protective equipment (PPE) when indicated. We observed full aseptic non-touch technique throughout theatre.

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) licence, in line with requirements for organisations that possess or supply controlled drugs regulated under the Misuse of Drugs Act 1971 and the Misuse of Drugs Regulations 2001. The service had an up-to-date policy for medicines management and code of practice for CDs, which leaders reviewed in May 2025.

Staff completed quarterly medicines management and CD audits, which focused on the safety, security, and safe administration of medicines. Compliance for medicines management was 100% between September and November 2025. The department audit lead and pharmacist completed quarterly CD audits. Compliance between July and September 2025 was 84% in theatres, 95% on Cornwallis ward and 100% on Mountbatten ward, against a target of 95%. The service repeated the audit of theatres in October 2025, achieving an improved compliance of 100%. The service discussed audit results in unit meetings and local medicine management meetings. Staff escalated concerns to the hospital’s Clinical Governance Committee (CGC).

Staff stored the CD register and CDs securely. We observed staff completing CD checks in recovery, including verifying items and expiry dates. Registers showed twice-daily checks. However, we noted some ‘block-signing’ in the theatre CD register, which did not comply with guidance requiring staff to sign at each stage of the process.

Pharmacists 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.

Staff kept medicines in a clinical room with keypad access, and cupboards in the room were locked. They kept keys for cupboards in a coded key safe in line with standards for good medicines management.

Staff maintained daily records of fridge, freezers, warming cabinets and room temperatures used for medicines storage. Temperatures were recorded consistently, with deviations escalated.

Staff reviewed each patient’s medicines regularly and provided advice to patients and carers about their medicines. Theatre staff placed a sticker in the notes of female patients who had received anaesthetic medicines that can reduce the effectiveness of hormonal contraception, and ward staff provided a leaflet advising additional contraceptive precautions for 7 days. The service displayed guidance posters to support safe antimicrobial prescribing.

The service’s monthly survey responses from September to November 2025 showed between 94% and 98% of patients felt that staff advised them about the potential side effects of medicines. Staff completed medicine charts fully. Staff recorded patient data needed for accurate medication doses such as weight. Staff also recorded any known drug allergies identified at pre-assessment.

Staff undertook prescription audits. Compliance for the period August to October 2025 was 94%.