The Droitwich Spa 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

The previous overall rating of safe at the Droitwich Spa hospital was good. Our rating remains good. The service had processes in place to manage safety incidents. When things went wrong, staff apologised and gave people honest information and suitable support. Staff had the required levels of training to safeguard vulnerable adults and children and took action to keep people safe from avoidable harm and abuse. There was continuity of care when people moved between different services. The design, maintenance and use of facilities, premises, and equipment kept people safe. The service had enough staff with the right skills, training and experience who received effective support, supervision, and development. Staff worked together effectively to provide safe care that met person’s individual needs.

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 service has 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.

Staff told us that learning from incidents and complaints was actively promoted. Incidents were reported through established electronic reporting systems and were discussed routinely during daily huddles, team meetings and governance forums. Staff described being supported by managers to raise concerns and said learning was shared within a no‑blame environment.

The service used structured approaches to learning and reflection. Staff described the routine use of Stop the Line and a Serious with A Rapid Methodology (SWARM) meeting.

SWARM is the provider’s approach to solving a problem or exploring an opportunity.

There was evidence of learning from the SWARM, which resulted in changes to practice.

Leaders maintained oversight of learning through the Patient Safety Incident Review Groups. Incidents were reviewed regularly with senior clinical input, actions were identified and monitored, and staff described receiving supportive debriefs following complex or distressing events, which helped reinforce reflection and learning.

Duty of candour was undertaken following any notifiable incidents. 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. Following a structured investigation, learning was shared with staff and actions taken to reduce the risk of recurrence.

The service held daily safety huddles, which included senior clinical leadership, such as the director of clinical services. These huddles were used to review and manage current risks, including serious incidents, equipment or environmental issues, patient acuity, safeguarding concerns, discharges and staffing levels. Staff told us these forums supported shared oversight and timely escalation.

The service 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.

The service’s referral and admission processes ensured that clinical and personal information about patients was received in advance of admission. This enabled staff to determine whether people’s needs could be met safely within the service.

Most patients undergoing surgery were assessed as low risk, and their needs could be safely met by the hospital. Pre‑operative screening processes supported appropriate case selection and escalation where additional complexity was identified.

Pre‑screening of surgical patients within the outpatient and pre‑operative assessment pathway ensured that people who required more complex care, or whose needs could not be met safely on site, were identified early and referred to alternative providers where appropriate. Staff described these processes clearly, and pre‑assessment records we reviewed supported this approach.

The hospital’s leadership team worked in collaboration with system partners, including the local NHS Trust and the integrated care board (ICB). Leaders described supporting local elective activity through planned surgical capacity.

Systems for transferring patients who clinically deteriorated were clear and effective. During our assessment, the hospital was delivering a high volume of orthopaedic surgery, particularly hip and knee procedures, for NHS patients. Staff were clear about transfer arrangements and escalation pathways, which provided assurance that continuity of care could be maintained when patients required onward specialist support.

The service 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.

All staff had received safeguarding training appropriate to their role and were able to describe and how to recognise and report abuse. Registered nursing staff were trained to safeguarding adults’ level 3 and safeguarding children level 2, while support workers were trained to level 2 for both adults and children.

The service had processes and systems in place to ensure staff requiring safeguarding training completed this in a timely manner, and managers actively monitored compliance and followed up outstanding training to ensure levels were restored promptly.

Compliance for safeguarding adults and children’s levels 1 and 2 training across the hospital was within hospital policy requirement, meaning staff were equipped with the knowledge and skills required to identify, respond to and escalate safeguarding concerns appropriately. Safeguarding adults level 3 training compliance for registered clinical staff was 100%.

Staff were familiar with the provider’s safeguarding policy, which set out how to identify, report and escalate safeguarding concerns. Staff we spoke with were clear about their safeguarding responsibilities and knew how to access advice and support from safeguarding leads and local authority safeguarding teams when required.

Hospital and service leaders demonstrated a clear commitment to safeguarding. Staff had access to a level 4 trained safeguarding lead in line with national guidance. The newly appointed Director of Clinical Services was planning to complete the level 4 training in the near future.

They provided examples of consulting on safeguarding concerns and described working with the local safeguarding board and ICB. Leaders also described how they accessed advice and support from local mental health and acute Trusts when required.

Safeguarding training included coverage of specific risks, such as female genital mutilation (FGM), and staff were able to describe how safeguarding risks would be identified and responded to in practice.

All eligible staff held valid Disclosure and Barring Service (DBS) checks appropriate to their role and level of patient contact. Staff had also completed training in the Mental Capacity Act and Deprivation of Liberty Safeguards (DoLS) and were able to describe how these principles were applied in practice.

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.

Staff understood how to manage people’s risks, including during emergencies. Clinical staff routinely used the National Early Warning Score (NEWS2) following surgery to identify and respond to deterioration. We observed staff carrying out routine observations during and after treatment and escalating concerns appropriately.

The service had clear exclusion criteria in place, which identified people with complex needs whose care could not be safely provided on site. These criteria were used to identify patients whose clinical complexity, anaesthetic risk, or postoperative care needs exceeded the hospital’s on‑site facilities, staffing, or escalation capability. The service took a balanced and proportionate approach to risk that supported people and respected the choices they made about their care and treatment. Individual risk assessments were complete and up‑to‑date.

The hospital had relevant policies and service level agreements to support the escalation and continuity of care where necessary.

This included arrangements with a private laboratory in Birmingham for access to emergency blood supplies and with neighbouring NHS hospitals for the transfer of patients who clinically deteriorated.

There was an Advanced Life Support‑trained Resident Medical Officer on-site 24 hours a day. They were supported by the senior clinical leadership and established on‑call consultant arrangements. This provided immediate access to medical review and escalation when required.

The service ensured that each shift had access to staff competent in Basic Life Support (BLS), Immediate Life Support (ILS) and Advanced Life Support (ALS). Shift planning and rota arrangements meant that staff with appropriate life‑saving skills were always available to respond to patient deterioration or medical emergencies.

Patient safety in theatres was supported through the consistent use of the World Health Organization (WHO) Surgical Safety Checklist and regular theatre safety huddles. These processes enabled teams to confirm key safety checks, share identified risks, and escalate concerns promptly, supporting effective communication and a proactive safety culture.

The hospital had implemented Martha’s Rule, which enabled patients, relatives and carers to request an urgent, independent clinical review of a deteriorating condition 24 hours a day, 7 days a week, if they felt their concerns were not being recognised or responded to. This supported patient involvement in escalating concerns and provided an additional safeguard to ensure timely clinical review and response.

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 facilities, premises, equipment and technology were tailor-made and designed specifically to meet the needs of the people who use the service. The design of the environment followed national guidance. For example, theatre imaging equipment met Ionising Radiation (Medical Exposure) Regulations (IR(ME)R) requirements, and specialist theatre equipment was routinely checked and serviced. This supported safe diagnostic care and surgical practice.

There was a service level agreement in place for sterile services. Staff ensured that equipment was available and appropriately processed to support theatre activity. We saw an example during our inspection where equipment had been updated. Orthopaedic equipment had been replaced following a successful business case due to the necessity to improve the reliability and suitability of equipment that were used for planned orthopaedic procedures.

The facilities department ensured the hospital building was maintained. Leaders described, and we reviewed, a planned programme of improvement, including work to improve theatre doors during a planned closure period, demonstrating proactive management of environmental risks. Where issues with theatre temperatures were identified, these were escalated through estates and governance processes and managed as a priority, with mitigation measures implemented to maintain patient safety and continuity of services.

Ward and theatre environments were clean, orderly and well-maintained. Equipment was checked and serviced in line with hospital and manufacture policy. We saw evidence that routine health and safety checks, including legionella monitoring, were in place and completed as required.

Patients were cared for in individual rooms and had ensuite bathrooms. There was a seated bay with reclining chairs for patients who were fit to sit following surgery, this had a bathroom area within it.

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.

Patients told us there were enough staff during and after their procedures and that the staff provided safe care and treatment. We saw staff available throughout the day who responded promptly to patient needs. We observed positive, friendly and encouraging interactions between staff and patients, and staff worked effectively with the multidisciplinary team to deliver care.

The service had enough medical staff to keep patients safe. Surgical procedures were carried out by consultant surgeons and consultant anaesthetists, the majority of whom were employed substantively by other organisations, usually within the National Health Service, and held practising privileges at the hospital. Arrangements for reviewing practising privileges ensured consultants practised within their agreed scope.

The service was supported by a Resident Medical Officer on site, providing immediate medical input and supporting patient safety at all times. The Resident Medical Officer worked closely with nursing staff, consultant surgeons and consultant anaesthetists to review patients, respond to deterioration and support escalation where required, including out of hours. This provided additional assurance that patients had timely access to medical review and supported safe, coordinated care across the service.

Staff received and completed training specific to their role, including bank staff. Mandatory training was completed annually, and the provider’s target for compliance was 95%. Managers had oversight of training compliance through monitoring systems and acted on any shortfalls. Training included equality, diversity, dementia awareness and learning disability awareness, which supported staff to adapt their communication and care delivery to meet individual needs safely and effectively.

Managers provided staff with regular clinical supervision and annual appraisals to support reflection, learning and professional development. We saw evidence that appraisal and supervision processes supported ongoing competence and professional revalidation. Staff were experienced, suitably qualified and had access to regular team meetings, and managers told us they addressed poor staff performance promptly and effectively.

Staff described having the skills, time and support to make reasonable adjustments in practice. They understood patients’ preferred communication styles and were able to access interpreting services and communication aids, including hearing loops, when required, in line with the Accessible Information Standard. Managers ensured staff knew how to access interpreters or signers promptly to support safe and inclusive care delivery.

We reviewed a sample of staff personnel records, including recruitment files for permanent staff (nursing, operating department practitioners, healthcare support workers and managers) and practising privileges documentation for consultants. These confirmed that fit and proper person checks were completed, staff were appropriately trained, onboarding processes were followed, and appraisal systems were in place.

The service had a stable workforce with low turnover and sickness. The ward generally operated a nurse‑to‑patient ratio of 1:6, which staff told us was often lower. Staffing was flexed in response to service need, including the use of twilight shifts to support patients recovering from theatre.

Mandatory training compliance had improved since the last inspection. A practice-based educator delivered onsite training and monitored compliance, while managers identified learning needs and supported staff development. Staff spoke positively about bespoke training opportunities, including shared training with a local National Health Service Trust and attendance at a joint sepsis conference.

All staff, including bank staff, received a structured induction appropriate to their role before starting work. All eligible staff had completed Advanced Life Support training. Ninety‑four per cent of eligible staff had completed Intermediate Life Support training or were booked onto forthcoming courses. However, 92% of eligible staff had completed Basic Life Support training, which was below the provider’s 95 % target. The service had planned additional sessions to ensure this training was improved.

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 clear systems in place to support effective infection prevention and control. All staff had received infection prevention and control and hand hygiene training and followed up‑to‑date policies to guide practice. Leaders maintained oversight through a structured audit programme, including surgical site infection surveillance, asepsis audits and antibiotic prescribing reviews.

Cleaning records were up to date, and environmental audits demonstrated high standards of cleanliness. An experienced infection prevention and control lead monitored compliance, supported staff and reviewed audit findings to identify areas for improvement.

The hospital had been awarded Aseptic Non‑Touch Technique (ANTT) accreditation, providing additional assurance of recognised standards in aseptic practice.

Patients told us the premises and equipment were visibly clean and tidy and had no concerns relating to environmental cleanliness. We observed staff following hand hygiene and ‘bare below the elbow’ guidance and using appropriate personal protective equipment, with access to sufficient hand hygiene facilities. Patients and visitors were encouraged to wash their hands, with clear signage in place.

Leaders undertook targeted audits to minimise the risk of surgical site infections. Asepsis and scrub audits achieved 100%, and the service carried out surveillance of surgical site infections, with all incidents reported and investigated to identify learning.

Staff screened patients for infections such as Methicillin‑resistant Staphylococcus aureus (MRSA), and isolation facilities were available to manage cross‑infection risks. Leaders reported no cases of MRSA in the 12 months before the inspection.

The service had a service level agreement with microbiology at the local NHS Trust and followed their protocols. Clinical and domestic waste was managed and disposed of safely, and linen and equipment were appropriately stored and segregated in line with infection prevention and control standards.

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.

Medicines were stored, prescribed and administered correctly. The hospital had a virtual pharmacy based on site, supported by a clinical pharmacist and pharmacy lead, to support medicines management

A pharmacist attended the hospital on scheduled days, with pharmacy technician support available at other times, and staff told us pharmacy advice was readily accessible. Patients were provided with clear information, including a list of medicines to obtain before their procedure, to support safe pain management and recovery following discharge.

The service undertook controlled drug checks twice a day. Medicines, including controlled drugs, were stored securely and at appropriate temperatures. Prescription stationery was securely managed in line with policy.

The pharmacy team participated in a programme of regular medicines audits to monitor compliance with hospital policy and identify learning. Audit activity assured that medicines management processes were followed in practice.

Medicines administration records were clearly presented, complete and up to date. On discharge, staff provided people with verbal and written information about their medicines, including what to do if they were unsure how to take them or experienced side effects. Staff sent discharge letters to people’s general practitioners to ensure continuity of records and ongoing care.

Staff followed good practice in medicines management in line with national guidance. This included medicines transport, storage, dispensing, administration, reconciliation, recording, disposal and the use of covert medicines where required.

The provider had effective systems in place to manage and respond to medicines safety alerts and recalls, supporting safe and timely action when required.