St Anthony's 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 Good. At this assessment the rating has remained Good. This meant people were safe and protected from avoidable harm.

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. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

There were systems in place to support clinical leads and managers in investigating incidents relating to the Outpatient Department (OPD). Between June 2025 and May 2026 there were 314 incidents reported within the OPD. The most common category related to OPD treatment, this accounted for 87 incidents. OPD staff told us they had taken action to address incident-related issues through the formal governance structures and provided feedback to staff locally, through their daily huddles. Information was also shared through daily and weekly briefing emails sent to staff and consultants. Printed copies of the huddle meeting notes were available in the OPD and pre-assessment areas. This meant staff who were unable to attend daily meetings were kept informed of incidents, learning, and training updates

Incidents were reviewed through a weekly rapid review meeting and regular governance meetings, which analysed themes and trends and shared learning. For example, following a mislabelled blood sample, heads of department discussed the incident, reviewed compliance with pre- and post-sample checks, and reinforced adherence to hospital policy.

Staff we spoke with understood how to report incidents using the hospital’s reporting systems. Staff described how learning from incidents was shared at daily departmental meetings, and we saw evidence of this in meeting records.

Staff we spoke with demonstrated an understanding of duty of candour, and were aware of where to find policies, with the OPD showing an overall training compliance of 100%. The policy was under review at the time of the assessment. We were told there were no OPD incidents requiring duty of candour within the last 12 months before our assessment.

The Heads of Department and members of the executive team attended weekly rapid review meetings and quarterly governance meetings, where they reviewed clinical and non clinical incidents. The hospital used the Patient Safety Incident Response Framework (PSIRF) to promote a culture of learning rather than blame. This supported the identification of underlying system factors contributing to incidents, enabling learning, improvement and safer care. In this way, the hospital’s reporting processes meant managers had oversight of incidents and supported the timely submission of statutory notifications. Staff told us there was a positive reporting culture, which encouraged openness, shared learning and effective risk management. Learning from incidents was shared through governance processes and team forums, including daily safety huddles.

For example, following a mislabelled blood sample, heads of department discussed the incident, reviewed compliance with pre- and post-sample checks, and reinforced adherence to hospital policy.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The service had systems and processes in place to support safe, coordinated and effective care. Whilst some challenges remained with appointment scheduling processes, leaders had recognised these issues and were taking action to improve the patient pathway.

Staff worked collaboratively together, with patients and other healthcare providers to plan, deliver and monitor care, helping to maintain continuity and safety, throughout the patient journey when care was transferred between services.

Referral processes supported patients in accessing the most appropriate care. Staff reviewed referrals before appointments to ensure patients were booked with suitable consultants. The service also tracked paediatric appointments to ensure appropriate staff and resources were available. Young people aged 16 and 17 years were risk-assessed to determine whether they were suitable to follow adult care pathways. This was supported by policies and procedures.

Arrangements were in place to identify and respond to deteriorating patients. Staff had access to policies and guidance for escalating concerns and transferring patients to NHS acute hospitals when necessary. These included clear arrangements for communication with receiving teams and the transfer of relevant documentation, medicines and equipment.

Staff worked effectively across professional groups. Consultants, nurses, healthcare assistants and support staff described positive working relationships, which was reflected in patient feedback. Daily departmental and hospital-wide safety huddles facilitated the sharing of information, risks and operational updates.

Patient records were maintained securely and were available when needed. We reviewed 12 patient records across the outpatient department (OPD) and pre-operative assessment (POA) service and found them to be complete, accurate and up to date. Paper-based patient records systems were used safely, and an electronic pathology requesting system was being developed to support service improvements.

Staff ensured patients were involved in decisions about their care and treatment. Patients were provided with information about procedures, and consent was obtained appropriately. Staff monitored patients throughout appointments and escalated any concerns to consultants, anaesthetists, GPs or other professionals as required. Processes were in place to support information sharing and safe handovers between teams and organisations, including for patients following NHS elective pathways.

Leaders recognised challenges associated with the implementation of a booking system introduced within the previous year. Appointments were arranged through a centralised, non-clinical booking team, which meant scheduling was sometimes driven by clinic availability rather than individual clinical needs. Staff and patients told us this could occasionally result in appointments not being booked at the most appropriate time or difficulties making late amendments. The hospital was aware of these issues and was working with consultants and their staff teams to help minimise the impact on patients.

The service provided elective NHS surgical pathways subject to the 18-week referral to treatment (RTT) standard. The types of treatment available and associated timescales were subject to contracts. However, leaders told us referral to treatment performance data was not routinely collected specifically for OPD appointments. As a result, the service could not demonstrate full oversight of RTT performance across all stages of the patient pathway.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They 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.

Safeguarding systems and processes were embedded within the service. Staff understood their safeguarding responsibilities and knew how to identify and escalate concerns. Staff had access to up-to-date safeguarding policies and procedures. Safeguarding information, including details of the safeguarding lead and escalation processes, was clearly displayed throughout the outpatient department (OPD). Although we identified some gaps in training compliance and opportunities to strengthen arrangements for children and young people, these did not significantly impact the effectiveness of safeguarding arrangements.

The service managed safeguarding concerns appropriately. There had been one safeguarding incident within the previous six months. Records showed safeguarding concerns identified during consultations were appropriately escalated, with referrals made and relevant information shared with external professionals, including patients' GPs.

Mandatory safeguarding training compliance was generally good. All registered nurses had completed safeguarding level 3 training for adults and children. However, compliance amongst healthcare assistants was lower at 69%, and leaders did not provide evidence of actions being taken to improve compliance.

Staff understood the principles of consent and their responsibilities under the Mental Capacity Act 2005. Policies and procedures were available to support decision-making where patients may lack capacity. Overall compliance with Mental Capacity Act and Deprivation of Liberty Safeguards training was reported as 100% for the department, although compliance was lower for some staff groups, such as healthcare assistants (77%) and nurses (80%). OPD staff told us they rarely encountered patients requiring formal mental capacity assessments, which was consistent with the patient care records we reviewed.

Patients told us they felt safe when attending the service and described staff as approachable, caring and supportive.

Arrangements were in place to support the safety of children and young people attending outpatient appointments. A dedicated waiting area was available, and signage reminded parents and carers that children should be supervised at all times. However, the area was not secured by swipe-card or keypad access, meaning it could be accessed by other patients and visitors. Leaders were aware of feedback regarding the potential use of the area as an overflow waiting space during busy periods. However, the service was unable to demonstrate that this potential risk had been formally assessed or that mitigating actions had been considered.

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.

All patients were triaged by a member of the pre-operative assessment (POA) clinical team, which meant patients had an individual risk assessment, taking into account clinical and social factors, to determine their suitability for treatment. Based on these initial triage assessments, patients would be excluded if the procedure required was outside the scope of the facility or if the patient's condition or co-morbidities are considered to pose too high a risk. It was at this stage that clinicians would decide whether further face-to-face or phone assessment was required or whether patients were more suitable for electronic-based assessments. Young people aged 16 to 17 years were assessed by the paediatric nursing team to determine their suitability for adult pathways.

Staff told us treatment-related discussions took place at initial OPD appointments and were revisited when obtaining consent. We observed this during clinical observations of staff practice.

Staff said that patients were given opportunities and supported to ask questions throughout their care. Patients said procedures were clearly explained, including risks and benefits, and that they felt able to ask questions and make informed decisions.

The service detected and controlled potential risks in the care environment. Overall, the OPD environment was safe, well maintained and supported the delivery of care. Systems were in place to manage premises, equipment and emergency preparedness. The outpatient department (OPD) environment was generally clean, well-maintained and suitable for the delivery of care. Reception and waiting areas were spacious, in a good state of repair and supported patient comfort and safety. Cleaning schedules were displayed throughout the department and were mostly completed. However, we saw some evidence of wear to flooring and noted occasions where daily public toilet cleaning records had not been completed. Leaders told us the hospital was undertaking a programme of refurbishment and improvement works.

There was clear signage throughout the hospital and OPD, which helped patients and visitors navigate the service safely and independently.

Processes were in place to ensure premises and equipment were maintained appropriately. Equipment was subject to regular servicing and tested appropriately, including portable appliance testing (PAT). Electronic reporting systems allowed the identification of maintenance issues and tracking of repair issues. Maintenance records showed actions were completed when required.

Consultation rooms were fitted with keypad access and contained call bell systems to enable staff to summon assistance when necessary. Staff-only areas were secured through swipe-card access systems. Although the OPD itself, including access to the designated children and young people waiting room were not swipe card or keypad restricted. Public toilets contained emergency pull cords to allow patients to request help if needed.

Adult and paediatric resuscitation trolleys were stored in accessible locations within the department. The trolleys we checked were well-maintained, stocked appropriately, and contained equipment that was within expiry dates. The department achieved 100% compliance with resuscitation trolley audits, and records demonstrated that regular checks were completed. Staff told us there was an established emergency response rota to ensure appropriate support during medical emergencies.

Staff understood their responsibilities for maintaining a safe environment and using equipment appropriately. Equipment and consumables were stored securely and generally within their expiry dates. During our inspection, we identified one blood sample bottle that had exceeded its expiry date, which staff removed when we brought it to their attention.

Fire safety arrangements were generally effective. Fire exits and emergency routes were clearly marked, and staff understood the procedures to follow in the event of an emergency. Weekly fire drills were undertaken, and designated fire marshals were available within the department and wider hospital. Fire extinguishers were appropriately located and maintained. During our inspection, we observed equipment temporarily obstructing access to a fire exit; however, this was addressed promptly and removed before the end of our visit.

Training compliance supporting the safe use of the environment in emergencies was generally good. Overall, OPD fire safety training compliance was good at 91%. However, compliance for some staff was low, such as nurses at 60%. The service was unable provide assurance that effective action was being taken to address these gaps and improve compliance.

Whilst we identified some isolated environmental issues and gaps in training compliance, these were not significant enough to affect the overall safety of the department.

The service made sure there were enough qualified, and experienced staff. They worked together well to provide safe care that met people’s individual needs.

Staff generally received the training, support and appraisals required for their roles. However, gaps in some mandatory training requirements and delays in appraisals during a prolonged management vacancy reduced assurance that all staff remained consistently up to date with essential training and development requirements.

The outpatient department (OPD) team included registered nurses, healthcare assistants and consultants working under practising privileges arrangements, supported by reception and administrative staff. Additional support was available from paediatric leads and nurses when caring for children and young people.

The service demonstrated a stable workforce. Staff turnover within the 12 months prior to our assessment was reported as 0%, and there were no vacancies in the OPD at the time of our assessment. Although there had not been a substantive Head of OPD since September 2025, a newly appointed Head of Department had commenced employment shortly before our visit. During the vacancy, leadership responsibilities had been shared between the OPD and Pre-Operative Assessment (POA) clinical leads, supported by senior leaders, including another Head of Department and a Clinical Services Leader.

Staff sickness rates were reported as 6.8% during the 12 months before our assessment. Leaders told us that approximately 25% of this absence was related to a single sickness episode. However, they did not provide evidence of specific actions to address staff sickness levels.

Staffing requirements were determined using an established staffing tool that monitored planned versus actual staffing levels and incorporated allowances for annual leave and training. The hospital used an electronic safer staffing tool, which was used across all Spire Healthcare Hospitals and had been created centrally. Although establishment figures between December 2025 and May 2026 were below calculated requirements, leaders explained this reflected the staffing model used rather than a staffing shortfall. At the time of our assessment, the nursing staff were above the planned establishment. .

The service did not use agency staff and relied on regular bank staff to support service delivery when required. Bank staff utilisation was 7.1% between May 2025 and April 2026. Data and feedback indicated staffing levels and skill mix were appropriate to meet patient needs.

Overall compliance with mandatory training was good. Compliance rates were between 90% and 91% or above. Training compliance was monitored through governance structures, including quarterly governance meetings, monthly departmental meetings, daily huddles and direct communication with staff.

Although additional clinical competencies were completed by OPD staff, some staff groups were not consistently up to date with mandatory training. Whilst overall compliance for safeguarding children level 3 training was reported as 100%, healthcare assistant compliance was 69%. Similarly, although overall information governance compliance was reported as 100%, compliance amongst healthcare assistants and nurses was reported as 69% and 70%, respectively. Basic life support training compliance was 90% overall, but lower amongst nurses (70%) and healthcare assistants (62%). The service was unable to demonstrate what actions had been taken to address these areas of lower compliance with mandatory training among some OPD staff groups.

The service did not provide separate compliance data for mandatory safeguarding adults training. Whilst competency records included safeguarding-related competencies, this reduced assurance that all staff had completed the required safeguarding adults training.

Appraisal compliance was generally good, with 92% of clinical staff and 100% of non-clinical staff having received an appraisal in 2025. Leaders told us performance had been affected by staff sickness and the absence of a substantive OPD manager, although a newly appointed Head of Department was in post at the time of our assessment.

Consultants worked within a practising privileges framework. Applications were reviewed by the Medical Advisory Committee before approval, and consultants were required to demonstrate ongoing compliance with professional registration, appraisal and mandatory training requirements. Leaders said practising privileges could be reviewed where consultants failed to meet organisational or professional standards.

The service assessed and managed the risk of infection.

Overall, systems and processes supported effective infection prevention and control. The department was clean, staff generally followed good IPC practice, and audit processes provided oversight of performance. Whilst we identified some gaps in cleaning documentation and an isolated deviation from hand hygiene practice, which was addressed, these did not significantly impact the overall effectiveness of IPC arrangements. The service had up-to-date infection prevention and control (IPC) policies and procedures aligned with national guidance. Staff monitored compliance through a programme of monthly and quarterly audits. We saw IPC audit results clearly displayed on the outpatient department (OPD) quality and safety board, helping staff and leaders monitor performance. However, similar information was not displayed as prominently within the pre-operative assessment (POA) area, reducing visibility of performance measures for staff working in that location.

The OPD, including the POA area, was generally clean, tidy and well-maintained. Cleaning schedules were displayed throughout the department, and cleaning records were routinely completed. However, we found instances where housekeeping records for public toilets had not been consistently signed each day in accordance with the provider's cleaning standards. This reduced assurance that daily cleaning checks had always been completed. Despite this, the service reported 100% compliance with monthly national cleanliness audits and 99% compliance with quarterly cleanliness audits.

Staff followed IPC practices designed to reduce the risk of infection. We observed staff adhering to the provider's bare-below-the-elbows policy, undertaking hand hygiene between patient contacts and cleaning equipment after use. Hand sanitiser and handwashing facilities were readily available throughout the department, and consulting rooms were stocked with appropriate personal protective equipment (PPE). Staff encouraged patients to use hand sanitiser on arrival, and IPC guidance was clearly displayed within clinical areas.

Compliance with hand hygiene audits was 100%, and equipment was clearly identified as clean and ready for use through the use of "I am clean" labels. We observed staff using PPE appropriately in line with guidance, including gloves and aprons where required. During the assessment, we identified one instance of incorrect hand hygiene practice. Leaders responded promptly by discussing the issue at the daily safety huddle and had arranged staff refresher training before the end of our visit.

Other IPC arrangements were effective. Disposable privacy curtains were within their replacement dates, flooring in clinical areas met required standards, and sharps were stored, labelled and managed in line with national guidance. The department achieved 100% compliance with sharps audits. Waste segregation was well managed, with quarterly audit compliance reported at 86%.

Patients told us the department was clean and they had no concerns about hygiene 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.

Patients who had questions or concerns about their medicines were supported to discuss these with their consultant or the hospital’s dedicated pharmacy team. Medicines, excluding Controlled Drugs (CD’s), were stored securely and safely; CD’s were stored outside of the Outpatient Department (OPD).

The OPD was 96% compliant in the quarterly departmental audits for medication storage. Medications were managed via the on-site pharmacy department. This included the availability of input from the out-of-hours on-call pharmacists. We were told that OPD consultants could provide private prescriptions, which allowed patients to fill their prescriptions using external pharmacies.

OPD staff did not prescribe medicines, as prescribing took place during consultations. However, there were on-site provisions for Patient Group Direction (PGD), the legal framework that allows UK healthcare professionals, such as nurses and pharmacists, to supply and administer prescription-only medicines to groups of patients without needing an individual doctor's prescription. This was supported by the relevant local policy for its application.

We reviewed a sample of medicines stored in the emergency trolley. All medicines we checked were stored appropriately and were within their expiry dates. Staff followed comprehensive medicines policies and guidance, including those relating to controlled drugs. Medication policies we observed were up-to-date and regularly reviewed.

Information on medication issues such as incidents, audits and learning was reported to the hospital’s weekly rapid review and quarterly governance meetings.