The Winterbourne 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 means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question as requires improvement. At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

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.

The provider, Circle Health, had an incident management policy that gave staff guidance about identifying, reporting, investigating and learning from incidents. Staff knew what incidents to report and how to report them. Staff reported incidents using the provider’s electronic incident reporting system. Multiple processes were used to share learning from incidents with staff. This included staff huddles and team meetings. Staff gave examples where changes had been made in response to incidents.

Staff were debriefed and received support after a serious incident. Staff gave examples when leaders had provided support following incidents that had an impact on their wellbeing.

The service provided outpatient appointments for NHS patients and was required to use the National Patient Safety Incident Reporting Framework (PSIRF) for those patients. This is a contractual requirement under the NHS Standard Contract. PSIRF is focused on learning from incidents to provide safer care to patients. Leaders said they used (PSIRF) to investigate and identify learning from incidents for all patients, (both NHS patients and privately paying patients). The incident management policy referenced and followed the principles of PSIRF. Following the requirements of the PSIRF, the provider had also published their Patient Incident Response Plan on their website. Following their analysis of reported incidents, the provider had identified patient safety priorities for the next 12 to 18 months across all hospitals in the Circle HealthCare groups and detailed how they would respond to the priorities.

From 1 August 2024 to 31 July 2025 the service reported a total of 77 incidents in the outpatient’s department. Of this total, 10 were graded as resulting in moderate harm, 22 resulting in low harm and 45 as no harm. The harm could be relevant to a patient, visitor, member of staff or to the running of the service. A review of incident investigation reports provided by the service demonstrated incidents fully were investigated and learning identified to reduce the risk of similar occurrence.

Staff understood the Duty of Candour. The service had not had any incidents in the outpatient service that necessitated Duty of Candour processes to be followed. Duty of Candour is legislation that requires healthcare providers to be open and honest with patients when things go wrong with their care and treatment. However, to demonstrate the hospital’s compliance with Duty of Candour requirements, they provided evidence of staff following the Duty of Candour process for a patient treated on the surgical ward at the hospital.

The evidence showed a good standard. The service worked to establish and maintain safe systems of care, in which safety was managed. They made sure there was continuity of care, including when people moved between different services.

The patient pathway, whether privately funded or funded by the NHS, ensured continuity of treatment by the same clinician while receiving care and treatment at the hospital. If additional treatment as an inpatient, such as surgery, was required, this was carried out by the same clinician who assessed the patient in the outpatient department.

Staff followed processes which ensured patients’ GPs received clinic letters to enable them to continue to provide care and treatment to the patient in the community.

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. The service knew to share concerns quickly and appropriately.

Staff had access to corporate policies about safeguarding adults and safeguarding children. The policies referenced national guidance and legalisation. Policies provided staff with clear guidance about types of abuse, how to recognise abuse and actions staff needed to take if they were concerned a patient had been subject to abuse and clear guidance about action staff needed to take in the event of an allegation of abuse.

Staff completed training about safeguarding people. Clinical staff received training about safeguarding adults and children. Records provided by the service demonstrated all staff, including administration and reception staff, had now completed training in both adults and childrens safeguarding that was relevant to their role and in line with national guidance.

Staff demonstrated a good understanding about safeguarding.

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.

Staff had access to policies and procedures to support them with assessing risk of harm and deterioration of patient’s conditions. This included a local Standard Operating Procedure for the transfer of patients to the nearby acute NHS trust in the event of a patient deterioration that could not be safely managed by the service.

All staff completed training about the care and communication of the deteriorating patient.

Should patients have any concerns, following their consultation, they could contact the department by telephone. Staff used the nationally recognised SBAR (Situation, Background, Assessment, and Recommendation) tool to assess and communicate information to the relevant clinician when patients contacted the service with concerns. SBAR is a structured communication method used to transfer critical information clearly and concisely, especially in healthcare settings. It provides a standardised framework for escalating problems, patient handovers, and critical communication to ensure effective communication, improved safety, and informed action.

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 outpatient department was tidy and free from ‘clutter’. Staff completed daily safety checks on all specialist equipment including the resuscitation equipment. Records demonstrated these were carried out daily and accordance with provider policy. Electrical equipment had been safety checked and maintained, indicating they were safe to use.

Suitable seating was available in the reception/outpatient waiting area. This included space for patients using wheelchairs and now bariatric seating.

Staff said they had sufficient equipment to carry out their work safely. Leaders had introduced a minor procedure booking process. Consultants who wished to carry out a minor procedure on a patient had to complete a booking form for the procedure. This meant staff could now ensure the correct equipment was available for the procedure.

Staff carried out annual risk assessment of the environment. The most recent Patient Led assessment of the Care Environment (PLACE) carried out in 2024 did not identify any concerns with the environment of the department. PLACE assessments are an annual appraisal of the non-clinical, including the environment, aspects of healthcare settings carried out by members of the public and staff.

Staff disposed of clinical waste safely. Waste was segregated and labelled in accordance with the hospital policy.

However, the service had a known issue with patient call bells with the system not always identifying the location where the call bell had been activated. This was an issue throughout the whole hospital and actions were taken to reduce the risks this posed. In the outpatient department, there were 2 consulting rooms that were not used due to unreliability of call bells. Staff said and we observed during the inspection this had no adverse impact on the safety of patients or the running of the service.

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 outpatient department had a dedicated team of registered nurses, and health care assistants. There were no vacancies at the time of the inspection. Staffing requirements were determined according to the clinical activity occurring in the department. This meant there were enough staff with the relevant skills and experience to safely provide care and treatment to patients attending the department. No bank or agency staff were used. In the event of staff shortages due to staff sickness, staff worked flexibly across the hospital to support the outpatient department.

The service had dedicated administration staff, who supported the administration and clerical side of the service. This included ensuring patient records were available for clinics and ensuring clinic lists were up to date.

Outpatient clinic sessions were booked directly by the consultant with the service. This ensured the consultant was always available to see patients in their clinics.

For nurse led clinics, such as dressing changes, the hospital’s resident medical officer (RMO) was always available for clinical support and guidance if needed.

Staff confirmed they received training and appraisals. All staff completed mandatory training appropriate to their roles. Records provided by the service showed for the 22 required mandatory training topics for nursing staff, there was only one topic where not all staff had completed it. This was because for 1 member of staff their training had expired, and they had yet to refresh their training. For administration staff there was a 93% to 100% compliance rate with their required 16 mandatory training modules. The training was appropriate for the patient group using the service. Information provided by the service showed all staff had received an appraisal in the 12 months preceding the inspection.

Consultants worked at the hospital under practicing privileges. This is when medical practitioners, in this case consultants, are granted permission to work in a private hospital or clinic in independent private practice, or within the provision of community services. The hospital followed process to gather assurance consultants had completed mandatory training. Consultants only carried out work they had been granted a practicing privileges for and remained as a registered practitioner on the General Medical Council (GMC) register.

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.

Staff had access to an infection prevention and control policy and supporting guidance to support them with infection prevention and control practices. They also had access to an infection prevention and control lead, to provide support and guidance.

The environment was visibly clean and had suitable furnishings which were visibly clean. Staff had access to personal protective equipment, such as disposable gloves and aprons as required for the activity they were carrying out.

There was an infection prevention and control audit programme that included use of personal protective equipment, hand hygiene, bare below elbows and the management of the environment and equipment in relation to infection prevention and control. The service provided data for the audits March 2025 to May 2025. These showed staff were compliant in all areas of infection prevention and control and there were no gaps in staff current practice.

Cleaning staff were visible within the department. Cleaning audits for the period March 2025 to June 2025 showed full compliance with maintaining the cleanliness of the department.

The evidence showed a good standard. The service made sure that medicines and treatments were safe and met people’s needs.

Staff followed the provider’s systems for the safe prescribing, administration and storage of medicines. Clinicians used prescription pads to prescribe medicine for patients. Staff followed process to securely store the prescription pads. There was a clear audit trail which detailed the date and time of when a prescription sheet was used, the serial number of the prescription sheet and the name of clinician who had used a prescription.

Medicines were stored securely with only authorised staff having access to them. Where medicines were administered, such as during a procedure, they were administered and recorded in line with the provider policy and national guidance.

The service monitored compliance with the safe management of medicines. Audits from February to July 2025 showed the outpatient service was 100% compliant with the medicines management systems.