Spire Southampton 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. We checked that people were safe and protected from bullying, harassment, avoidable harm, neglect, abuse and discrimination.

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

This service scored 72 (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 positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Staff raised concerns and were encouraged to report incidents by their managers. The service had clear policies for incident management, which were accessible to all staff. They explained how to report, categorise, and investigate incidents. Incidents were discussed within governance meetings and team meetings. The progress of recently reported, ongoing and closed incident investigations were discussed daily in morning safety huddles that leaders from all departments attended. This was then disseminated to staff.

Managers investigated incidents thoroughly and implemented changes where needed. There was an overall positive culture for incident reporting and learning and staff were able to give examples of changes made following incidents. Where learning was required, there were processes to follow for staff to ensure this was shared and embedded. We saw evidence of debriefings following incidents to support staff and support learning. Staff told us that changes had been made because of feedback. Most staff said that lessons learnt from incidents were clearly communicated to staff and that they were informed about incidents that happened. We also observed that the staff who told us that they were always informed about incidents had worked for the service longer than 3 years.

The service shared incidents and learning from other hospital locations to ensure learning was widely shared. We saw examples of where these had been shared in newsletters and `flash alerts' regarding medicines.

We reviewed all incidents reported within the service from the 6 months prior to onsite inspection and saw that they had or were being investigated in line with policy.

The service had 2 Never Events in the last 12 months. Never Events are serious incidents that are preventable if processes in place are followed. These incidents were being investigated as a matter of priority and in line with internal policy. We reviewed the incident investigations, which were still underway at the time of inspection. We saw that changes had been made and learning identified. This included increased administrative support for printing theatre lists, and familiarisation for staff in procedures they do not always work on.

Most staff knew what incidents to report and how to report them via the online reporting system. However, we found in theatres that incident reporting when items, such as swabs were left in the sterile field was not completed. Staff we spoke with were unaware that this should be reported under the services' own policy. This limited the ability to improve practice.

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. Staff made sure there was continuity of care, including when people moved between different services.

Staff had access to resources like checklists and guidelines, which supported them to undertake the correct actions during an emergency. This supported staff to escalate concerns to the right people and services when under pressure. Resident doctors were able to attend all deteriorating patients without delay due to their proximity to wards. There was also an on-call theatre team to support rapid return to theatres.

The service had facilities onsite to support patients who deteriorated. For patients who required specialist interventions such as care following a stroke, there were safe transfer systems in place. Staff reported transfers on the service's incident reporting system. There had been 37 deteriorating patients who had been transferred to other hospitals following between February 2024 to 2025. Leaders reviewed these to ensure that appropriate and timely escalation had taken place and where appropriate investigated to determine service improvement.

There were 31 incidences of `same day' cancellation between December 2024 to 28 February 2025. The service had up to date processes in place to ensure that patients were rebooked following cancellation of surgery. Cancellations were reviewed to determine if they were avoidable or unavoidable. For all cancellations, actions were taken on the day where possible. In some cases patients were unable to be contacted but this was followed up and actions taken in line with policy. Of the 31 cancellations 4 were determined to be avoidable. We saw that in instances of avoidable cancellation these were investigated to improve process and prevent repeated occurrence. Apologies were also always given to the patient.

Emergency equipment in theatres and wards was checked regularly with daily and weekly checks, according to best practice guidelines. Emergency medicines were supplied by pharmacy, and these were sealed in bags with expiration dates clearly visible. Pharmacy staff told us they were aware at least 3 months in advance of medicine expiration so this could be proactively replaced.

Patients discharged following surgery were given a `We hope you're blooming well' card, which provided contact details for a 24 hour phone number should they feel unwell or have additional questions. Patients were given information about their prescribed medicines, when to call for help, and advised to contact the service if they were admitted to another hospital within 31 days of surgery. In the 12 months prior to inspection, there were 68 unplanned readmissions following surgery, with the majority of these patients being readmitted at a Spire Hospital. During this period there were 9,843 discharges, meaning the readmission rate was less than 1% of patients who underwent surgery.

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. The service shared concerns quickly and appropriately.

Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff knew how to make a safeguarding referral and who to inform if they had concerns. The service had safeguarding processes and procedures in place that were clear, easy to access and in line with current best practice. At the time of the inspection all staff were trained to level 2 safeguarding adults and 99% were trained to advanced safeguarding children. For level 3 adult safeguarding, all ward staff had completed and in theatres, all support staff and 98.9% of registered staff had completed this. All staff who were required to undertake safeguarding at a level 4 had completed this. There was a designated safeguarding lead for the location who supported departments in raising safeguarding alerts This gave a consistent approach to reporting.

We reviewed 61 incidences of safeguarding concerns and referrals for both adults and children completed by the service. These were completed in line with policy and appropriate actions taken and documented.

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.

There were clear and concise inclusion criteria for patients to have surgery at the hospital. This ensured that patients who needed surgery were in the most appropriate hospital setting for their needs.. Consultants reviewed all cancellation and postponements. A RAG rating system (red, green, and amber system) was in place in the pre-operative assessment (POA) department, this took into account surgical comorbidities such as pre-existing diseases and mobility. A pre-operative patient safety review form was available for patients who fell outside inclusion, such as patients comorbidities that would increase surgical risk or mental health issues. These patients were referred and reviewed in admission assessment meetings that were attended by anaesthetists and consultants, along with their medical notes. We saw that, where appropriate, risk assessment and clinical discussion was undertaken to see if they could be supported to attend and treated quicker rather than remain on waiting lists for NHS services. This was then documented with an admission assessment meeting tracker. We reviewed examples of patients who did not meet inclusion criteria. The Hospital director was fully involved in these discussions. This improved access for patients and was in line with services' patient centred values.

All patients attended a pre-operative assessment appointment (POAA) to identify any risk factors and additional requirements. These were then fully documented in patient records. All pre-operative clinical tests were completed in line with National Institute for Health and Care Excellence (NICE) guidelines. Risk assessments to assess a patient's risk of developing blood clots, also known as venous thrombo-embolism (VTE), were always completed before and after surgery. The VTE pre operative assessments were completed in all 4 sets of notes we reviewed, and preventative measures were given where appropriate. The VTE risk assessment was also checked the day after surgery, this was in line with best practice. We saw pre operative assessments were completed in 45 sets of notes we checked. In the notes we reviewed VTE post operative assessment was only completed in 3 of the 4 sets of notes we looked at. We raised this with ward staff who took action to complete this.

Staff used a nationally recognised tool called the National Early Warning Score 2 (NEWS2), to identify deteriorating patients and escalated them appropriately. There was also a policy for how to manage a deteriorating patient within the service. We looked at 4 sets of notes on the ward and these were all completed. During our review of the NEWS2 charts, we found these were calculated and escalated correctly. This meant nursing staff ensured doctors reviewed any patients with a NEWS2 of 4, enabling early detection and treatment of deterioration.

The service used the `5 steps to safer surgery', World Health Organisation (WHO) surgical safety checklist, in line with National Patient Safety Agency guidelines. The WHO Surgical Safety Checklist is a 19-item tool designed to reduce errors and adverse events in surgery by improving teamwork and communication. It is used globally by most surgical providers and has been shown to significantly decrease surgical morbidity and mortality. In theatres, we observed safety checklists being completed immediately before and after surgery, for all procedures our team were present for. This meant staff effectively communicated vital information as a team, ensuring patients were kept safe.

The service had a critical care Level 3 unit, which was always available to receive patients who required enhanced clinical care. Level 3 critical care, also known as an Intensive Care Unit (ICU) or Intensive Treatment Unit (ITU), provides the highest level of intensive care for patients with the most severe and life-threatening conditions. The service had 2 doctors residing onsite at all times, this would be increased if there was cardiac surgery of which the third was a cardiac specialist. This meant the service could care for deteriorating patients at this hospital, unless the patient required specialist urgent care, such as stroke. There was a service level agreement in place with the local NHS Trust for transferring critically unwell patients. There were practical drills annually to ensure the processes were effective. The service also implemented team huddles for night staff to ensure all patients were safe. These were then adopted across other services under the provider.

Staff had the relevant life support training for their role. At the time of the inspection, training compliance for Immediate Life Support (ILS) was 89% for theatre staff and 63% for ward staff. ILS training focuses on providing frontline healthcare professionals with the skills to manage a cardiac arrest before more advanced support arrives, including skills like oxygen therapy and airway management. Recovery staff were only 75% complaint in ILS; however, they were fully compliant with advanced life support which is a more advanced level and more suited to the patients they may receive post-surgery. As the provider training completion date was April 2025 and the target was 95% these figures were expected to meet this target.

All theatre staff took part in a theatre huddle at the beginning of each morning to discuss the patient list for that day, any ongoing investigations and any recently reported. In addition to this, each operating theatre team performed their own team brief before starting each operating list. We observed a team brief where staff discussed each patient on the list, effectively communicating risks, allergies, medication and equipment needed.

We followed several patient journeys through the operating theatre department at different stages of care in the theatre department. The WHO checklists, team brief and debrief were being undertaken in each theatre and completed in line with local policy and national guidelines(or standards). All teams performed a brief and debrief for each theatre list. We reviewed 10 team briefing records which had been fully completed. There was an on-call team for theatres overnight if a patient needed to return to theatre. There was a theatre huddle at the beginning of each shift with all of theatre and then at the beginning of each surgical list. We observed a huddle and saw they discussed each patient on the list, risks, allergies, medication and equipment needed. We followed a patient journey and saw the WHO checklist, brief and debrief being undertaken in theatre and they were all completed well. All teams performed a brief and debrief for each theatre list. We saw 10 team briefing sheets; all of them were fully completed. There was an on-call team for theatres overnight if a patient needed to return to theatre.

The evidence showed some shortfalls. The service did not always detect and control potential risks in the care environment. Staff mostly made sure equipment, facilities and technology supported the delivery of safe care.

The ward area and theatre were suitable for their purpose and the ward area was clutter free. We also observed theatre staff modifying an item used for surgery by cutting tapes off of surgical swabs. These tapes were then disposed of in the waste bin. This did not follow the standards set in the National Safety Standards for Invasive Procedures 2 (NatSSIPs) or the service's own policy for ensuring all items are accounted for during invasive procedures. These national standards cover all invasive procedures, including those performed outside of the operating department.

The service' policy required that staff incident report when items were modified during surgery. This was to ensure leaders were informed of these instances, so they could make changes or improvements. However, we reviewed incident reporting for the service and saw no evidence that staff reported these incidents. We spoke with staff who told us they had raised concerns surrounding this practice, however we saw no evidence of this being raised under FTSU processes.

In addition to this `red ties' from theatre swabs were kept in the sterile field during surgery, despite not being accounted for on the theatre count board or during checks. This practice had been normalised and was not in line with the service's own policy or national standards. The service monitored compliance against the `5 Steps to safer surgery' under NatSSIPs and this showed 100% compliance. However, the most recent best practice standards NatSSIPs2 recommend that a more comprehensive 8 step check is performed. This meant that the service was not yet auditing standards according to the current best practice. Both practices increased the risk of items being retained in patients following surgery and this risk was compounded by the failure to incident report when swabs were left in the surgical field. However, we noted that incident reporting for the service showed no instances of patient harm in relation to retained items.

We raised this with the provider on the day of inspection and were advised that actions were immediately taken to remedy this. This included leaders highlighting the importance of white board usage in several safety huddles, and planned installation of updated white boards that were designed specifically for monitoring National safety standards for invasive procedures (NatSSIPS2) compliance. Provider level guidance which incorporated the NatSSIPS2 clinical guidelines was being centrally reviewed at the time of inspection.

Additionally, the service policy on retained items had been reissued to all relevant staff to review and acknowledge. This was further supported by discussion of reporting responsibilities and the policy in a range of meetings and safety huddles. The theatre clinical specialist was also undertaking observational compliance monitoring to ensure this learning was embedded.

In addition to this we found a theatre equipment storeroom that was cluttered. Some equipment used for safe patient positioning during surgery had been stored on the floor, instead of appropriate storage shelves or units. This posed a risk to patients for infection control and to staff as a trip hazard. This area was raised with senior leaders following inspection and in response actions were taken to improve this area. This included installation of increased shelving and development of an inventory system which grouped together items based on the frequency of use.

In one operating theatre, we also found items containing natural latex rubber stored with latex free items. This posed a risk of cross contamination and meant that patients allergic to latex could have been inadvertently exposed. However, there were no incident reports relating to latex allergies, which demonstrated that no patients had come to harm. We escalated this to the service and were advised that the interim theatre manager would be undertaking work to improve staff understanding of products that may contain latex. They also planned to implement a trolley of items that were latex free to be stored separately. There was also a provider level project which planned to remove all latex products from services. We checked over 100 single use items in stock rooms for theatres and all 3 wards, and all were in date.

The design of the environment followed national guidance. The service had enough suitable equipment to help them to safely care for patients. In theatres we reviewed equipment servicing history and saw all equipment was in date. All equipment we checked onsite contained evidence of in date electrical safety testing and servicing. However, our data review showed that on Ward 2 & 3 there were a small number of items that has passed their servicing date and there was no evidence to suggest this had been addressed. There was good availability of equipment within the theatres. Staff said there was advanced planning of schedules which meant they could ensure equipment was readily available. There was a dedicated team that undertook maintenance and oversight of equipment faults. Where indicated, external providers were contracted to undertake servicing.

The service had processes in place for the maintenance and checking of electrical equipment in accordance with Managing Medical Devices (January 2021), and other national guidance.

Emergency equipment for the wards was stored centrally with clear access. There was a resuscitation policy which required staff to check the emergency equipment daily. We saw staff carried out daily checks of specialist equipment. The trolley was secured with a tag which was removed monthly to check the entire contents were in date. We saw that this was completed in full where the ward was in use. We saw examples of equipment that had been removed from use when it had expired and replaced. Theatre staff had access to specialist emergency equipment, such as a difficult airway trolley, and these were checked regularly. We saw all equipment had electrical testing completed. We checked the resuscitation equipment on the ward and in theatre; daily checks were completed in all areas. This meant staff protected patients from harm, by effectively and safely managing equipment.

Patients could reach call bells on the ward and told us staff responded quickly when called. All patient rooms were single occupancy to prevent any risks of cross infection. However, we saw daily checks for suction and oxygen equipment in patient rooms across all 3 wards, had not been completed accurately or in line with policy. This increased the risk that should this be needed it may not be functional an inhibit response to deteriorating patients. We raised this with the service and saw action was taken to immediately address this. We also observed areas in patient rooms and ward areas where furniture and furnishings appeared worn. Patient feedback also referred to areas in patient rooms that they felt were not as well presented. Leaders told us that a large refurbishment of the hospital had been approved and planned to begin in June 2025, this would include patient areas and furnishings.

There were 6 theatres in total, all had the appropriate air management systems to maintain sterility. The airflow systems in the operating theatres were validated and checked against standards set out in national guidance Health Technical Memorandum 03-01; "Specialised ventilation for Healthcare Buildings" 2021. The service completed an environmental audit annually. Theatre staff told us the equipment manage for the service was easily contactable if equipment needing replacement or repairing.

Each theatre had its own scrub area, anaesthetic room, and prep area. All anaesthetic rooms were set up the same. This meant staff knew where equipment was even when allocated to different theatres. Staff were trained to use specialist equipment safely and had annual updates. We saw staff disposed of clinical waste safely. We reviewed all policies covering waste disposal and clinical specimen management processes and saw that these were clear, easily accessible and in line with current national guidance. Within theatres, there was a 1-way system for the disposal of waste. We reviewed environmental audits undertaken in theatre which showed the area had 100% compliance in Stop before you block', `Safer surgery Theatres' and `Safer surgery cataract' audits.

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.

The service had enough nursing staff with the right qualifications, skills, training, and experience to provide the right care and treatment. The service used a staffing model to determine the staff needed on wards and in theatres based on the acuity of patient. This was planned in advance and reviewed as part of daily huddles to identify upcoming shortages and on the day shortages such as unplanned sickness. This staffing model showed the total required staffing for the service. The aim of the service was to staff permanently at 90% with 10% of workforce made up of temporary staffing. This ensured flexibility in line with activity and ensured continuity of service was maintained. In theatres, assistant theatre practitioners provided scrub cover in response to national shortages. Non registered theatre staff were only permitted to scrub for specific procedures that were listed in service policy and matched national guidelines issued by the Perioperative Care Collaborative PCC.

The theatre lead planned theatre lists 1 month in advance, which was also reviewed by senior leaders, including the hospital director. This meant they were able to plan and deliver the correct level of staffing in line with surgical activity. Staff were experienced, qualified, and had the right skills and knowledge to meet the needs of patients. Managers made sure staff received specialist training for their role. All staff had competency booklets to complete, which were relevant to their role.

During our onsite inspection, we found the number of staff in theatres and wards matched the planned numbers. We observed a morning huddle where staffing numbers for each department were discussed. Staff helped each other out and ensured they worked together to achieve safe care for the patients. Areas that had staff shortages were supported by staff from other areas that were also familiar with procedures in that area. We observed discussions about staffing arrangements in morning leader huddles. The most recent staff survey had identified that recruitment was a priority to ensure that staff from other areas were not utilised to cover staff shortages.

We reviewed induction materials provided for bank and permanent staff. These contained information regarding familiarisation, service values, line manager reviews and role-based competency records. Managers arranged theatre training for staff which included specific training relevant to their role and also held team meetings.

Consultant surgeons and anaesthetists saw patients at the service under practising privileges (PP's). Practicing privileges are an agreement between a healthcare professional, like a doctor, and a private healthcare provider, usually a hospital, that allows the professional to provide care at the provider's facility. These privileges are granted based on checks of the professional's qualifications, experience, and suitability, ensuring they meet the facility's standards. PP's were granted solely at the Hospital Directors discretion. The hospital had a medical advisory committee (MAC) who advised on governance and clinical issues. The MAC committee also reviewed PP's in terms of scope of practice and competence.

Each theatre list was booked for a timeslot and appropriate staff were allocated. This was achieved by using a staffing matrix that determined the acuity of the theatre list and the staff required to deliver this. We heard from the on-call theatre team that there were occasions where theatre lists overran. Staff told us that they were concerned that when on-call staff were utilised to cover late running lists, this posed a risk to patient safety as it may affect their ability to respond to a deteriorating patient. We raised this with the service on the day of inspection. Leaders assured us that 4pm `safe staffing' huddles were used to effectively assess staffing levels for theatre overruns. Following our inspection the service also told us that that on call staff had not been used to staff overrunning theatre lists, since January 2025.

Staff undertook a wide variety of training relevant to their roles and responsibilities such as medical device training, NEWS2, and infection prevention and control. Mangers monitored staff training to ensure this was completed. The service goal was 95% completion of all mandatory training by April 2025. Most departments had reached or exceeded this goal. Staff in the pre-operative assessment team had completed 100% off their assigned training.

However, manual handling training compliance in ward and theatres staff had a combined compliance of 53%, with the lowest compliance for registered ward staff at 26.3%. Data provided by the service showed that registered ward staff had the lowest training completion rate within the surgical workforce, with 15 of the 32 mandatory training modules below the 95% compliance target. Leaders acknowledged that this training was below the service target and in response advised they had introduced protected time every 2 months in all clinical areas to support staff to complete training and attend meetings. The further advised they would be adding a training calendar of events for the remainder of the current training year, April 2025-2026.

The evidence showed a good standard. The service assessed and managed the risk of infection. Staff detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. The service took action to address any shortfalls.

The service had a clear Infection prevention and control (IPC) policy, this reflected current guidance. Staff followed infection control principles including the use of personal protective equipment (PPE). Staff had access to PPE including aprons, masks and gloves in a variety of sizes. Staff cleaned their hands before, during and after patient contact. We saw signs reminding people to clean their hands in areas we visited. Hand sanitiser was available in every room and at the entrance to the ward area and theatres. We reviewed audits in IPC and saw that they were completed in line with policy. Where these audits identified areas of improvement with a score of less than 95%, action plans were made with clear actions. These were then completed in a timely manner. For example, an audit for October- December 2024 scored below the set threshold. We reviewed the action plan and saw the target had been met, and compliance was above 95% for the period January- March 2025.

There was a clear housekeeping policy for the cleaning tasks to be completed before, during and post discharge for patient rooms. We reviewed housekeeping records that evidenced cleaning of patient rooms in line with policy. However, staff on the ward were unable to describe how they determined if a room had been cleaned and made ready for use. This posed a risk of patients being admitted into rooms, before cleaning had been carried out. This was raised on the day of inspection and the service made immediate changes to practice. Leaders told us housekeeping staff attached `I am clean' signs to entry doors once cleaning was completed. Ward staff were positive about this change.

Theatre areas were noted to be visibly clean and well-organised. All staff we saw during our inspection were `bare below the elbows' and dressed in line with the service's policy. We saw staff cleaning equipment appropriately following theatre cases. There were separate scrub, anaesthetic, and preparation rooms for each theatre. There were cleaning records available in each area in theatre and we saw these were completed in full. However, there were worn areas of the walls in theatres that posed an IPC risk due to the inability to be cleaned. Staff in theatres has raised these and they were on the service risk register.

Ward areas were clean, well-organised and had suitable furnishings. During our inspection there were areas throughout the service, in ward areas, corridors and stairwells, where carpets were worn and required replacement. However, the service had a fully approved plan to replace flooring throughout in the months following the inspection.

Staff cleaned equipment after patient contact and labelled equipment to show when it was last cleaned. We saw all equipment in patient areas displayed `I am clean' stickers from the date of inspection. We reviewed service policies regarding surgical site infection and these reflected NICE guidance NG125. There were procedures in place to reduce risk and monitor signs of Surgical Site infections (SSIs) in line with NICE CG 74 Surgical site infections: prevention and treatment. Patients who met service criteria were screened in pre-assessment for Methicillin-Resistant Staphylococcus Aureus, before admission. The service completed SSI surveillance 30 days post-surgery for all patients who had had a hip or knee replacement. Between March 2024 and February 2025, SSI rates were reported as Hip Arthroplasty 0.34%, Knee Arthroplasty 0.47%, Spinal 0.24%and Coronary Artery Bypass Graft 1.06%. While most of these rates are below national levels, the rate of SSIs for Knee Arthroscopy was slightly higher. Knee arthroscopy is a minimally invasive surgical procedure where a surgeon uses a small camera (arthroscope) and other instruments to look inside the knee joint and diagnose or treat various knee problems. The service told us they were aware of this elevated rate and had identified a root cause and were working to improve patient outcomes.

The evidence showed a good standard. The service made sure that medicines and treatments were safe and met people's needs, capacities and preferences. Staff involved people in planning, including when changes happened.

Staff followed systems and processes to prescribe and administer medicines safely. Doctors prescribed medicines on a paper-based chart. This was stored within patients' nursing record. Pharmacy teams ensured the best use of medicines through interventions and regular ward visits. Pharmacy staff told us they visited wards at least three times a day, carrying out medicines reconciliation and checking drug charts, intervening where necessary. Medicines reconciliation is the process of accurately listing a person's current medicines. This could be when they are admitted into a service or when their treatment changes. Staff also provided advice to patients when they were prescribed new medications. Antimicrobial audits looked at whether antibiotics were safely used. Regular audits were carried out to ensure medicines were reconciled, prescribed, administered, and stored in line with national guidance and hospital policy. Where appropriate, intravenous antibiotics were swapped over to oral forms after 48 hours. This was in line with best practice. Patients taking oral antibiotics are less likely to experience IV related infections, to miss any doses and to suffer adverse effects from medications. We observed that medicines throughout theatres and wards were locked and secure. We saw medicines were always stored safely in line with recommended practice. Medicines storage and security checks were undertaken and recorded regularly. Controlled drugs (CDs) were stored safely and securely with access restricted to authorised staff. Checks were undertaken daily and recorded by registered staff in their respective areas such as wards and theatres. The keys for the medicine cupboards and CD cupboards were held by the nurse in charge of each ward. Checks of CD's and records showed that they were within date and stock balances were accurate. Theatre controlled medicines records were completed in full, with clear audit process recorded. The Controlled Drugs register audit for theatres for the 3 months prior to inspection which showed 99% compliance and the ward 96%. We reviewed the CDs book on the ward during our inspection and found no discrepancies in the recording of CDs.

Pharmacy staff gave examples of where audit process had resulted in action. The audit for `Receipt and recording of patients own CDs' had shown compliance below target at 90%. Actions for improvement were identified and included all nursing staff repeating CD training, recirculation and evidence of receipt of the CD policy, and posters reminding staff of bullet points on CD cupboards. Staff were also advised to ask, if a patient brought CDs when they were admitted that relatives were asked to take patients own CDs home as the service would supply this and enable better oversight of medicines.

Staff told us that they knew how to contact pharmacy for advice and processes were in place for the supply of medicines. Staff told us how they had access to relevant medicine policies, procedures, and guidelines. The ward had sepsis kits which were readily available and contained all items required These were all in date with clear oversight and checking by pharmacy staff. The pharmacy team spoke positively about the service and the level of support they had. Staff also said that there was a good relationship with the pharmacy team. Staff did not have specific medicines optimisation training, but where appropriate to their role, staff undertook Controlled Drugs training.

There was a clear process in place for managing and reporting any incidents involving medicines. Staff were able to talk through the process that would be followed if this occurred. There was a good safety culture that encouraged staff to report these. Patients were given advice at pre-operative assessment to stop taking certain medications which may interfere with their procedure. Staff had accurately recorded these conversations in patient's notes.

The pharmacy team explained how they had clear processes and oversight of medicines via spreadsheet systems, to check expiry dates regularly. Pharmacy was available to support wards with managing medicine processes such as feedback from audits on medicine management, ordering and receiving medicines. There was a medicines management lead for theatres. They attended quarterly medicine management meetings and actioned any requirements from it. There were various methods across the service, for implementing medicines updates and information. This included 48 Hour Flash Safety Alerts, Monthly Colleague Safety Bulletins, and National Medicines Management Meetings. We reviewed evidence from these communications and saw evidence changes were implemented and actioned in a clear and consistent way.

Medicines for refrigeration were stored securely. The maximum and minimum temperatures were taken electronically and monitored by the pharmacy department to ensure the medicines were stored safely. Staff knew how to escalate any temperature breaches and what action to take to ensure safe medicine storage. The ward had medicines trollies which were on wheels. Staff moved them around when doing drug rounds and we observed these were locked when not in use.

Documentation of medicines administration, including routes of administration and times of administration were clear on all medicine records reviewed. The allergy status of patients was routinely recorded on all medicine records we reviewed. Processes were in place to record pain assessments and that appropriate pain relief was prescribed, administered, and recorded. Accessible pain scoring charts were also available for patients with dementia or a learning disability who were unable to easily communicate their pain. The service used a pain scale that had different facial expressions to indicate pain levels. Accessible pain scoring involves using pain assessment tools that are easy to understand and use, especially for individuals with limited communication abilities or cognitive impairments. These tools often use visual aids, simple language, and behavioural observations to assess pain levels.