The Ridgeway 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 looked for evidence that safety was a priority for everyone, and leaders embedded a culture of openness and collaboration.

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

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 had a proactive and positive culture of safety, based on openness and honesty. Staff and leaders listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. Learning was shared with staff.

The service managed patient safety incidents well and staff described a structured and embedded learning culture. Staff reported incidents using an electronic incident reporting system to log and track incidents and actions were taken to mitigate risks of reoccurrence. There were daily communication meetings to review incidents.

There were policies and standard operating procedures (SOPs) to support staff and leaders in managing incidents effectively. This included an SOP following the introduction of a national patient safety incident response framework. All incidents were discussed in the Governance Committee monthly.

Leaders investigated incidents and shared lessons learned with the whole team and the wider service. Leaders ensured learning from incidents from other locations were shared to inform staff and prevent similar incidents. Staff told us about learning from an incident which included the use of a formal team debrief and a reflection session and this resulted in shared learning and strengthened team preparedness for future emergency situations.

Staff understood the duty of candour. When things went wrong, staff apologised and gave patients honest information and suitable support.

Managers ensured actions from patient safety alerts were addressed and progress was monitored. Information regarding new alerts was shared each morning in a whole service meeting.

The service reported 122 incidents between June 2025 and May 2026 with 33 incidents (31%) graded as ‘no harm’, 87 incidents (71%) grades as low harm and 1 incident was reported as moderate harm. The service also reported 1 death in the last 12 months prior to the assessment.

There had been no reported never events in the preceding year. Never Events are serious, preventable safety incidents which should not occur if the available preventative measures are followed.

Incidents were analysed to identify trends or themes and potential links to individual practitioners. However, we reviewed 1 incident investigation and 2 ‘structured judgement reviews’ (a structured approach to a clinical review) following the death of 2 patients. We noted there were gaps in the documentation of the ‘timeline’ document, the learning response lead was not identified and there were no questions posed to formulate key lines of enquiry. It was not evident from the information shared how the incident had been graded and the level of investigation that had been undertaken. However, following the assessment service leaders shared further evidence which demonstrated the level of harm was considered and recorded and the incident was investigated.

The service worked with patients and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. Staff made sure there was continuity of care, including when responsibility for patient care moved between different areas of a service and between providers.

Safety and continuity of care were priorities throughout people’s care pathways. There were comprehensive pre-assessment and standardised observation booklets designed to provide a consistent approach to patient care. This included fluid balance charts and pain assessment.

We walked the patient journey and tracked patient care from admission to either ambulatory care or the inpatient ward, to the operating theatre and through to discharge. We observed handover of patient information including all related identification checking processes. Staff gave patients information about who to contact if they were concerned following discharge.

Staff followed clear patient selection criteria to ensure that only patients whose needs could be safely met by the service were accepted. These criteria outlined the service’s limitations and reduced risk by excluding patients whose needs fell outside the scope of care provided. As there were no enhanced care facilities available onsite, patients were required to be suitable for standard ward-based care following surgery.

The booking team received electronic referral forms from consultants and processed these using an electronic patient administration platform. There was clear guidance to manage and rebook appointments if patients did not turn up or the procedure was cancelled. Data showed there had been 16 cancelled operations between 3 March 2026 and 26 May 2026 with the reasons for cancellation recorded. Data showed 11 (69%) of these had been rebooked within 28 days in line with the service’s policy. Three procedures were not rebooked, and 2 procedures were not rebooked within 28 days although the reasons for this were not shared

Staff understood surgical safety standards such as ‘a stop the line’ policy which empowered staff to pause a procedure if they had any concerns about patient safety and told us they would use it if needed. In the operating theatre, we observed staff completing the World Health Organisation (WHO) surgical safety check list to prevent avoidable harm. Service leaders audited compliance to ensure safe surgical processes. For example, data showed 100% compliance with ‘Stop before you block’ and between 96% and 100% compliance with quarterly audits of compliance with the WHO surgical safety checklist in the last 12 months prior to our inspection.

Staff received training on how to identify a deteriorating patient and completed vital observations in line with national guidance. When vital signs deteriorated, staff escalated concerns to medical staff who reviewed patients in a timely manner. The service audited compliance with the recording of vital signs and the escalation of deteriorating patients. These audits were undertaken quarterly and demonstrated compliance rates between 93% and 99% from May 2025 to April 2026.

The transfer of patients from the operating theatre to the recovery was managed safely, with the anaesthetist retaining responsibility for determining the readiness for transfer. Suitably skilled and qualified staff accompanied patients in all areas.

There were effective arrangements to ensure patients received the care and treatment they needed, including out of hours. The operating theatre department had an on-call team so that they could attend out of hours if needed. There was an onsite pathology department that processed blood samples and ensured blood transfusions could be administered following strict checking processes in line with national guidance.

There were effective processes to transfer patients to NHS hospitals if they deteriorated and needed additional clinical care. When overall responsibility for the care and treatment of a patient moved to a different service provider, such as transfer to the NHS, there was effective communication, which allowed for seamless transfer.

There was access to some diagnostic procedures onsite and there was a service level agreement to access diagnostic services at a local NHS trust if needed.

The service worked with patients and healthcare partners where required, to understand how best to keep people safe, what it meant for individuals and the best way to achieve that. Staff concentrated on protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Staff understood how to protect patients from abuse, and the service worked effectively with other agencies to do so. Staff demonstrated awareness of their safeguarding responsibilities, including how to identify concerns, and safeguarding information was routinely shared during handovers.

The service ensured staff were trained and supported to recognise and respond to safeguarding concerns. Mandatory and enhanced safeguarding training was delivered and monitored, including scenario-based refresher sessions. Multi-agency learning was embedded through safeguarding supervision sessions, which incorporated serious case reviews and local learning. Staff also accessed specialist training on the Mental Capacity Act, Deprivation of Liberty Safeguards, trafficking, and domestic abuse. There was strong collaboration with external partners, including local authorities and the police.

Staff received adult and children's safeguarding training at a level required for their role and were required to complete this training every two years. Leaders monitored compliance through a dashboard, with escalation processes when completion rates fell below 90%. This helped ensure staff were trained and supported to identify and respond to safeguarding concerns. Data showed compliance rates of 98.1% for safeguarding vulnerable adults training and 97.2% for children's safeguarding level 2 training (March 2026). The local safeguarding lead had completed level 4 safeguarding training.

Current safeguarding policies reflected national guidance for both adults and children. These policies included guidance on meeting the needs of patients with additional vulnerabilities or support needs.

Staff knew how to identify adults and children at risk of, or experiencing, significant harm and worked with other agencies to protect them. They knew how to make a safeguarding referral and who to inform if they had concerns. The safeguarding lead was available Monday to Friday and provided out-of-hours on-call support. Staff knew how to contact the safeguarding lead and understood the processes that followed the raising of concerns. Effective links with external agencies helped ensure appropriate action was taken when safeguarding issues were identified.

They were able to give examples of how they protected patients from harassment and discrimination, including individuals with protected characteristics under the Equality Act 2010. Staff received training in the Mental Capacity Act and Deprivation of Liberty Safeguards.

Discharge and follow-up arrangements were organised safely. Patients understood what to expect following discharge and knew when they would next be reviewed by a nurse or doctor.

Staff followed safe procedures for visitors to the wards, including children. Patients we spoke with told us they felt safe while receiving care from the service.

The service did not always work well with patients to understand and manage risks. Staff did not always provide care to meet patient’s needs that was safe, supportive and enabled patients to do the things that mattered to them. However, staff monitored patients’ vital signs and had effective processes to transfer patients if required.

Service leaders monitored compliance with venous thromboembolism (VTE) risk assessments through regular audits. However, audit results consistently remained below the service target of 95%. Quarterly audit data showed improvement over time, increasing from 84% between April 2025 and March 2026 to 88% in April 2026 and 89% in May 2026. Leaders were aware of the shortfall and continued to monitor compliance and drive improvement.

Risk assessments were person-centred and were generally reviewed regularly. For example, VTE risk assessments were completed at pre-admission, on admission and reviewed following surgery. The initial assessment was not always undertaken by a registered practitioner. Where tasks had been delegated, registered nurses reviewed and signed the patient records. Healthcare assistants told us they escalated any risks they identified to registered nursing staff.

Staff monitored patients and recorded vital signs using a nationally recognised early warning system. They had access to guidance on recognising and responding to the deteriorating patient and received relevant training to support this. Staff completed life support training required for their role.

The service had effective systems for transferring people to a nearby NHS trust when their needs exceeded the level of care the hospital could safely provide. Between August 2025 and March 2026, 6 patients were transferred. Four of these transfers followed surgery due to post-operative complications. These incidents were recorded as clinical incidents and reviewed in line with the service's incident management and investigation procedures.

We spoke with 8 patients and 1 relative during the assessment. Patients told us they felt listened to, had risks explained to them, and were involved in decisions about their care and treatment.

The service did not always detect and control potential risks in the care environment. Leaders and staff did not always make sure equipment, facilities and technology supported the delivery of safe care or that there was appropriate mitigation of the risk.

In the operating theatre department, we noted a fire escape route that was partially obstructed by overflow of equipment stored in the area. Staff were aware of the risks and did their best to keep the pathway free but had nowhere else to store the equipment. However, fire safety equipment was available and had been serviced and staff told us that fire drills were carried out.

Staff mostly carried out daily safety checks of specialist equipment. However, we saw some gaps in completion of daily safety check lists both in the operating theatre and on the inpatient ward. When items were noted to have expired their use-by date, they were not always removed and replaced, meaning there was a risk of using consumables that were no longer guaranteed to be fit for purpose. We raised this with service leaders during the inspection, who took action to replace out-of-date consumables and re-iterate the importance of thorough daily checks.

Staff did not monitor the temperature where medical implants were stored. However, the ambient temperature in the department was monitored. We raised our concerns with the theatre manager who took immediate action to implement temperature monitoring as part of daily safety checks. In addition, service leaders reviewed the manufacturer’s specifications and were assured the optimal temperature had not been exceed because of the air conditioning in the immediate environment.

Hazardous substances were not always stored safely. During the inspection, we found 3 containers with chlorine-based cleaning products stored in a sluice in the operating department, when they should have been stored in a designated and locked cupboard in line with Control of Substances Hazardous to Health (COSHH) regulations. In addition, the COSHH cupboards should be kept locked, and we observed there were intermittently left unlocked. We raised this with service leaders who took immediate action to ensure the safe storage of substance hazardous to health.

There was a hospital wide asset register of all medical equipment and due dates for servicing, which showed 100% compliance. However, data from governance meeting minutes (May 2026) highlighted a list of 88 pieces of equipment on the Health & Safety Committee Report & Escalation Report, including EBME (May 2026). Of these listed pieces of equipment,77% of equipment was serviced within the due date. However, staff identified that 17 pieces of equipment were not recorded on the equipment tracker to ensure they received regular servicing.

Staff did not keep the door closed between the dirty utility area and recovery in the operating department. This meant there was a risk that equipment and consumables stored in the connecting corridor could be contaminated. We fed this back to the theatre manager who took prompt action to raise awareness and arrange for cleaning of the equipment stored in the connecting corridor. However, staff disposed of clinical waste safely, both inside and outside the building. Waste was segregated and labelled in accordance with the trust policy. The risk of sharps injuries was minimised because of the safe management of sharp implements.

The design of the environment followed national guidance around the built environment. Where required, areas were secure and protected patients. Access to the operating theatres was restricted by swipe card access and a doorbell.

The environment of the wards and other areas used for patient care reduced the risk of patient harm, and included, for example, safe flooring and window restrictors.

There was suitable equipment provided and used correctly, such as for patients who were at increased risk of pressure damage or a blood clot developing.

Staff had access to resuscitation equipment on the ward and in the operating theatres. If there were any concerns about resuscitation equipment, this was raised in a daily whole-hospital safety briefing meeting and cascaded to all staff on duty. It was also re-iterated in a daily resuscitation meeting where roles and responsibilities were discussed and assigned to people designated to answer calls for clinical emergencies.

There were processes to ensure the compliance with health and safety concerning fire safety.

Specialist equipment used in the operating theatres was used in accordance with national guidance and regulatory requirements. However, staff had identified concerns regarding the reliability of drills used in orthopaedic operations. Staff mitigated this risk by maintaining access to additional drills and reporting equipment faults through appropriate processes. During the inspection, we observed theatre staff collecting 2 additional drills for an orthopaedic operation as the drill used was not working correctly. The equipment lead had ordered 2 additional drills but there was a risk that there could be a shortage of working drills as there were 2 further orthopaedic operations scheduled. Service Leaders were aware of the issue and had implemented a replacement programme.

When radiology was used in the operating theatres, staff were wearing appropriate protective lead/aprons and carried ‘dose monitoring’ equipment to monitor radiation.

Patients could reach call bells and staff showed patients how to use them to summon help. We saw call bells were responded to swiftly and the noise level from unanswered call bells was minimal.

The service made sure there were adequate numbers of qualified, skilled and experienced staff, who received effective support, supervision and development. Staff worked together well to provide safe care, which met patient’s individual needs.

The service had effective recruitment processes which ensured pre-employment checks were completed for new staff. There were systems to monitor ‘Disclosure and Barring Service’ (a check of a person’s criminal record) checks and to support registered professionals to maintain professional registration and revalidation where required. Poor performance was managed appropriately and supportively, with processes to ensure fair and equitable outcomes.

The service had enough nursing, support and allied health professional staff to meet patients’ needs and keep them safe, although there was some reliance on bank medical secretaries. Staff had the required qualifications, skills, training and experience for their roles, supported by clear policies defining responsibilities and scope of practice.

Consultant surgeons and anaesthetists underwent an effective practising privileges process (the granting of formal permissions to healthcare professionals, allowing them to provide specific clinic services within a particular healthcare setting). This included regular appraisal and revalidation reviews. Leaders and consultants described good working relationships, which supported continuity of consultant cover. A resident doctor was available on-site with access to consultants at all times, including weekends.

Managers reviewed staffing levels and skill mix in line with clinical activity and patient needs and could adjust staffing levels accordingly. Staff told us they were able to take breaks during shifts and felt the service was safe. Patients told us their needs were met promptly, and we observed staff responding quickly and providing kind, supportive care.

The service had a low overall sickness rate of 3.5%; however, some departments experienced higher levels of sickness, including medical records (21.8%) and pharmacy (13.9%) in April 2026.

Staff received regular support through supervision, appraisal and professional development opportunities. Appraisal compliance was 83.1%, although rates were below 75% in six staff groups. Consultant appraisal compliance was 100%. Opportunities for career development were available, and staff spoke positively about the support they received.

Managers held regular team meetings; however, attendance was variable, particularly within theatre and ward teams. Meeting minutes were shared with staff to ensure key information was communicated.

Mandatory training compliance was high at 97.9%, with only three modules below 95% compliance. Role-specific training compliance was also high at 96%, although four subjects were rated amber or red. Staff were provided with specialist training relevant to their roles, enabling them to deliver safe and effective care.

The service assessed and managed the risk of infection. Staff detected and controlled the risk of it spreading by following policies. Infection and prevention and control data was collected and reviewed. Where required, actions were taken to improve shortcomings.

The service had effective systems and processes to assess, monitor and manage the risk of infection in line with national guidance. There were arrangements to identify and prevent surgical site infections. If surgical site infections were suspected, these were investigated further. Data showed there had been no surgical site infections reported between 1 January and 31 December 2025. However, minutes of the governance committee meeting in May 2026 showed there had been 4 incidents of infections reported of which 1 had been confirmed as an infection.

A designated infection prevention and control (IPC) nurse led on IPC activity, including audits, training and investigations, supported by the local Director of Infection Prevention and Control.

Staff followed infection prevention and control policies and procedures, used personal protective equipment appropriately, and demonstrated good hand hygiene practices. Equipment was cleaned after patient use and labelled to show when it had last been cleaned. Staff understood procedures for managing body fluid spillages and adhered to the service’s uniform policy, including being bare below the elbows.

Clinical areas, including theatres and wards, were visibly clean and well maintained. The management of sterile and used surgical equipment reduced the risk of cross-contamination, and sterile packs were checked before use. Surgical instruments were decontaminated and sterilised through an external provider under a service level agreement.

The service undertook a programme of IPC audits, including hand hygiene, aseptic non-touch technique and theatre asepsis, with recent audits demonstrating good compliance across clinical areas.

However, the service had not yet fully embedded the NHS National Standards of Healthcare Cleanliness, including the use of national cleaning audit processes and cleanliness ratings. The Circle Health Group (CHG) was reviewing the CHG Housekeeping Manual and remained committed as an organisation to review standards against national best practice and updating them where changes provided meaningful improvements in patient safety, infection prevention and environmental cleanliness. The new version was due to be published in December 2026.

The service made sure that medicines and treatments were safe and met patient’s needs, capacities and preferences. Staff involved patient in planning, including when changes happened.

There were processes to support people with their medicines when they attended for surgery. Staff completed risk assessments prior to surgery and managed people’s regular medicines in the perioperative period.

Medicines were stored safely and securely on the wards. Staff managed short-dated medicines effectively, reducing waste where possible. Temperature monitoring was completed regularly and medicines checked were within their expiry. Controlled drugs (CDs) were kept securely, and record keeping was done in line with national guidance. However, we found one medicine in the operating theatre that was out of date. We raised this with staff who took immediate action to remove and replace this.

The surgical wards received support with medicines reconciliation and discharge from the pharmacy team. Pharmacy staff were available on the wards to counsel people on changes to their medicine prior to discharge, as well as make interventions to support safe prescribing. Take home medicines were prepared in advance of people’s discharge to prevent delays in them going home. On occasions where pharmacy was closed and unable to dispense discharge medicines, nurses gave people To Take Away packs (TTA). There was a clear process in place for the use of TTA packs, and we observed staff following this process. People were given clear information about their medicines on discharge. A specific pain leaflet was available, and people were given a QR code to access videos of pharmacists explaining various medicines commonly used post-surgery. Staff told us people liked these videos because they could rewatch them at home in their own time.

People’s heights, weights and ages were documented on their prescription charts. A medication history, using multiple sources of information, including record of allergies was recorded in their charts. Venous thromboembolism (VTE) risk assessments were completed for all the people we reviewed, and prophylaxis was prescribed where necessary.

Staff had access to medicines resources to support their practice such as Injectable Medicines Guidance. An app was used to access local NHS Trust guidance on antimicrobials and venous thromboembolism. These local practices had been adopted by the provider to ensure uniformity across the local area.

A system of medicines audits was ongoing and results, and associated action plans were monitored at the Medicines Optimisation Committee. There were systems to receive, disseminate and action medicines safety alerts.