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

We looked for evidence that safety was a priority for everyone, and leaders embedded a culture of openness and collaboration. Leaders had systems for identifying and responding to deteriorating patients on the wards, in the operating theatre and recovery. People received treatment and care to reduce the risk of avoidable harm, such as pressure damage, blood clots or falls. There were safety processes arranged before surgical procedures and operations started, with staff working together to ensure the right patient had the correct operation. Medicines were managed safely. Patients were safe from neglect, abuse and discrimination. Patients gave informed consent prior to procedures and where they were unable to consent, those close to them were involved in decisions made in their best interests. However, not all staff were up to date with their mandatory and role specific training.

At our last assessment we rated this key question Good. At this assessment the rating has remained Good. Patients were safe and protected from avoidable harm.

The service was in breach of legal regulation in relation to mandatory training.

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. However, not all staff were up to date with their training.

From 1 June 2025 to 31 May 2026, the service reported 600 incidents. This was mostly related to unplanned admission following day case (15%), pathology sample (13%), theatre service (11%), patient deterioration (10%) and unplanned readmission (7%). The service reported 20 incidents classed as near misses (3.3%). Most incidents were graded low or no harm.

Incidents were analysed to identify trends or themes and potential links to individual practitioners.

The service had a current incident reporting and reviewing policy, which reflected the provider and national guidance. Staff told us they had received training before the Patient Safety Incident Response Framework (PSIRF) initiative was implemented in the hospital in 2024.

The service managed patient safety incidents well. Staff recognised and reported incidents and near misses. Staff raised concerns and reported incidents and near misses in line with provider policy. Staff were able to identify and report risks, secure in the knowledge these would be addressed. Where there was an immediate risk of harm to patients or others, staff felt confident to intervene to prevent harm occurring. Staff received feedback from investigation of incidents, both internal and external to the service.

Managers investigated incidents and shared lessons learned with the whole team and the wider service. Managers ensured actions from patient safety alerts were addressed and progress was monitored.

We saw evidence of incidents having been investigated, and sufficient action taken to reduce the risk of recurrence and the service made changes following incidents and complaints. For example, the service had changed their pregnancy test kit due to a faulty batch reported. The service had also re-educated staff on regular repositioning of patients particularly those classed as high risk or immobile.

Staff received feedback from incident investigation through handover, ward meetings and newsletters. We saw examples of learning from incidents around documentation and consent included in the recent ‘Feedback Friday Newsletter’. Following a recent never event, the service introduced a ‘pause step’ before key stages of procedures to allow teams to stop and re-check decisions to improve patient safety. Staff told us they discussed incidents regularly, in a supportive environment, and reviewed themes and outcomes.

There had been 1 recently reported never event in the preceding year. However, this was not reported to the commission in a timely manner. Never events are serious, preventable safety incidents which should not occur if the available preventative measures are followed. They include things like wrong site surgery or foreign objects left in a person’s body after an operation.

Managers debriefed and supported staff after any serious incident, including opportunities to reflect on practice. Staff told us they received a good debrief following the recent never event in the service.

Staff understood the duty of candour. They were open and transparent and when things went wrong, staff apologised and gave patients honest information and suitable support. We observed duty of candour stickers being used in patient records to highlight when the duty of candour process had been initiated. This supported consistent documentation, provided a clear audit trail, and helped ensure that statutory duty of candour requirements was completed in a timely manner.

The service provided mandatory training in key skills to all staff. Overall mandatory training compliance for clinical staff was 92%. However, compliance was below the provider's 90% target for some training modules within pre-assessment, theatre and ward staff groups. This included information governance, controlled drugs, management of medical devices, the Mental Capacity Act and Deprivation of Liberty Safeguards, with compliance ranging from 50% to 88%. These gaps reduced assurance that staff had received all training considered necessary by the provider to support the safe delivery of care and treatment.

Compliance data for non-clinical staff showed an overall completion rate of 96.5%. Training data for non-clinical staff on the wards, pre-assessment, and pharmacy showed they were compliant with their training. However, not all non-clinical theatre staff were up to date with their training modules particularly equality, diversity and inclusion (EDI), information governance, basic life support level 2, mental capacity act and deprivation of liberty safeguards. Low compliance in these topics ranged between 50% and 67% for non-clinical staff.

Clinical staff completed training on recognising and responding to vulnerable patients for example, patients with mental health needs, learning disabilities and dementia. Staff were up to date with the Oliver McGowan training on learning disability and autism.

Managers used changes in national guidance, incidents, safeguarding and appraisals to identify gaps in learning.

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 was a priority throughout people’s care pathway. Patients were assessed prior to surgery and findings taken into account when planning care and treatment. This may include cancelling or delaying the surgery in cases where an underlying condition was identified.

There were admission criteria for private, insurance, and NHS patients. These criteria set out where they had limitations in services and therefore minimised risks by excluding some patients. For example, people with high risk of needing additional support such as those requiring rehabilitation, and intensive care or high dependency care post operatively. Patients requiring tests and investigations were given enough information to enable them to understand the procedure.

There were systems and processes to ensure the correct patients were treated throughout the patient journey. We walked the patient journey and tracked patient care from admission, to the wards, and to the operating theatre. We observed handover of patient information including all related identification checking processes. Once in theatre, we observed the World Health Organisation (WHO) surgical safety check list was used to avoid harm. Staff confirmed the surgical safety standards such as a stop the line process was understood by them in the event of any concerns raised. The service had 5 steps to safer surgery team briefing and a briefing record was completed for multidisciplinary (MDT) team and included items like what went well, what didn’t go so well, any equipment issues, controlled drug (CD) register completed, theatre register completed and any reportable incidents that required escalation.

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.

Patient records were paper based and were kept securely.

Consideration was given to whether a patient was likely to require critical care support and when necessary, this was planned in advance. Staff told us this ensured robust planning and been prepared for all patients been admitted for surgical procedures.

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 supported continuity of care.

Care and support was planned and organised with people, together with partners and communities, in ways which ensured continuity of care.

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. However, not all staff were up to date with their safeguarding training modules.

Staff received adult and children's safeguarding training. Compliance with safeguarding training was high across most staff groups, with 99.2% of clinical staff having completed the required modules. Non-clinical, pre-assessment and pharmacy staff were also up to date. However, compliance among non-clinical theatre staff was below the provider's target, with 50% compliance for safeguarding adults level 3 training and 67% for safeguarding children level 3 training. These gaps reduced assurance that all staff had received the safeguarding training required to identify and respond appropriately to safeguarding concerns..

There were current safeguarding policies, and these reflected the national guidance for adults and children, including visitors.

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. Expert safeguarding advice was available to support staff from Monday to Friday. Staff knew how to contact them. There was a named nurse and named doctor for adult/child safeguarding. The service also had a paediatrician lead and children's nurses for safeguarding for 16 – 18 year olds.

Staff considered safeguarding concerns when incidents occurred and sought further advice or made referrals when necessary. There were links to external agencies, staff attended local safeguarding meetings and staff knew what happened when they raised concerns.

From 1 December 2025 to 31 May 2026, staff reported 3 safeguarding referrals in the service, which demonstrated active identification and escalation of risks.

Staff knew how to identify adults and children at risk of, or suffering, significant harm and worked with other agencies to protect them. Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act.

The director of clinical services, deputy director of clinical services, and the children and young people nursing services managers had oversight of safeguarding within the service and provided safeguarding support to staff. Discharge and follow up arrangements were organised safely. Patients knew what to expect and when they would be next seen by a nurse or doctor.

Staff followed safe procedures for visitors visiting the wards and patients we spoke to told us they felt safe.

The service worked with patients to understand and manage risks. Treatment and care met patients' needs in a way which was safe and supportive and enabled them to do the things that mattered to them.

We spoke to 9 patients during our assessment who told us they felt listened to, risks had been explained, and they were involved in decisions about their care and treatment.

Patients across all specialities told us that their families and loved ones were also encouraged to be involved in decisions about their care, where appropriate.

Staff used the National Early Warning Score (NEWS) to identify patients at risk of deterioration and escalate concerns appropriately. Audit data showed compliance with NEWS scoring was 99.9%, exceeding the provider's 90% target.

Staff knew about and dealt with any specific risk issues and risk assessments were observed being discussed during staff handovers. The service carried out various risk assessments audits such as venous thromboembolism (VTE), pain, steps to safer surgery. Data showed that staff achieved 100% compliance in the risk assessment audit and over 98% compliance in the VTE, pain, pregnancy testing, pre-operative fluid fasting and in the World Health Organisation (WHO) surgical safety checklist audits.

Staff achieved 98.3% compliance in the stop before you block audit. This is clinical safety audit designed to measure compliance with a national surgical checklist process that prevents wrong-site anaesthetic nerve blocks.

Staff also achieved 100% compliance in the prosthesis pause audit. This is a clinical safety audit used in surgical theatres to measure compliance with mandatory double-checking procedures before any permanent medical implant or prosthesis is cemented, screwed, or inserted into a patient.

Medical staff were trained in advanced life support and European paediatric advanced life support which ensured they were competent in advanced skills to expertly manage cardiac arrests and deteriorating patients.

The service detected and controlled potential risks in the care environment. Leaders and staff took steps to make sure equipment, facilities and technology supported the delivery of safe care. Where they were unable to do so, they mitigated the risks.

The design, maintenance and use of facilities, premises and equipment kept people safe. The design of the environment followed national guidance around the built environment. Where required, areas were secure and protected patients. Access was restricted by swipe card/doorbell into theatres.

Since the last assessment, the service had undergone some refurbishment. This included refurbishing main reception, installing dementia friendly sign in reception, and replacing sluices on the wards. The service had also repaired 3 theatre doors, replaced pantry on St Georges ward, replaced windows and blinds on St Theresa ward, upgraded the bleep and nurse call system. The service had a refurbishment plan, which included further improvements to theatre areas, replacement of pipework and increased storage capacity in 2026.

Staff were trained to use equipment and to manage different types of waste safely.

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

Fire safety equipment was available and had been serviced. Fire exits were clear and free from obstruction.

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 carried out regular safety checks of specialist and emergency equipment. There was ready access to resuscitation equipment on the ward and in theatres and all consumables and emergency medicines were up to date.

Specialist equipment used in the operating theatres was used in accordance with national guidance and regulatory requirements.

The theatre intraoperative temperature control audit which evaluated compliance to perioperative thermal guidelines to prevent hypothermia, showed 93% compliance against a target of 90%.

Leaders maintained oversight of equipment to ensure it was safe and ready to use. Equipment audits were completed and outcomes shared with staff. Staff told us they had enough equipment to carry out their work safely and to support the treatment and care needs of patients. The service had effective processes to ensure broken or missing equipment was repaired or replaced.

Patients could reach call bells. Call bells were positioned by patient beds, 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 had suitable facilities to meet the needs of patients’ families when necessary. Patients we spoke with felt the wards were well equipped and said they felt safe and comfortable during their stay.

Staff disposed of clinical waste safely, both inside and outside the building. Waste was segregated and labelled in accordance with the hospital policy. The risk of sharps injuries was minimised because of the safe management of sharp implements.

Hazardous substances were stored safely and information about products was available to staff. Patients reported that lighting was reduced at night, and the noise levels were minimised.

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 enough clinical staff including nursing and support staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. Staff were made aware of their shifts in advance and could make requests.

The hospital employed 17 whole time equivalent (wte) managers, 7.85 wte support workers and 62.51 nurses, operating department practitioner and perfusionist. A perfusionist is a trained healthcare professional who operates a heart-lung machine during open-heart surgeries.

New staff received a full induction tailored to their role before they started work. Managers supported staff to develop through constructive recorded, annual appraisals and constructive clinical supervision of their work. Data showed that 91% of multidisciplinary staff were up to date with their appraisal. Temporary bank and agency workers had a local induction to the area in which they were working.

Managers reviewed the number and grade of clinical staff, healthcare assistants, and other key roles needed for each shift using a safe staffing tool in accordance with national guidance. Managers could adjust staffing levels daily according to the needs of patients. Theatre, ward and recovery staffing was planned, based on activity and the skills needed for everyday and emergency work, including out of hours cover. We saw duty rotas for the last 2 months, which showed shifts were filled to match the planned activity and acuity in the service.

The service had low vacancy rates. At the time of the assessment, the service had 3 vacancies in theatres for a perioperative practitioner and 2 theatre assistants.

The service had reducing turnover rates. The average turnover rates in the last 12 months was 12.3% and mostly related to theatre and ward staff.

The service had low sickness rates. The average sickness rate was 4% against the 5.1% hospital average.

Managers limited their use of bank and agency staff and requested staff familiar with the service. From May 2025 to April 2026 the average use of bank staff was 10% and 0.1% for agency use. Where agency staff were used, evidence of their suitability was provided.

Staff said they felt the service was safe. They were able to take breaks during their shift.

Patients spoken with felt their needs were met in a timely way and we observed staff responded quickly to call bells. We saw patients were attended to in a kind and supportive way. Patients appeared comfortable and were engaged in conversations because there were sufficient staff.

The service supported the learning and development needs of staff and made sure staff received any specialist training for their role. Managers identified any training needs their staff had and gave them the time and opportunity to develop their skills and knowledge. For example, staff in theatre had completed an external training on robotics before the robotic assisted surgery was implemented in the service.

Managers made sure staff attended team meetings or had access to the information shared, when they could not attend. We saw notes from team meetings and other general information was shared on notice boards.

Managers supported staff to develop through constructive recorded, annual appraisals of their work and regular clinical supervision. If poor staff performance was identified, this was dealt with in a supportive way, with a view to improvement.

Allied healthcare professionals formed an integral part of the patient care and treatment pathway and promoted recovery and rehabilitation.

The service had sufficient allied health professional staffing to meet patients' needs and support timely care and discharge planning. There was oversight of medicines optimisation and ward-based support for staff from a pharmacist.

The provider supported the learning and development needs of staff and made sure staff received any specialist training for their role. Managers identified any training needs their staff had and gave them the time and opportunity to develop their skills and knowledge.

The service had formal arrangements for a resident medical officer (RMO) to be on-site when patients were receiving treatment and care. In independent hospitals, a resident medical officer (RMO) is a doctor who provides continuous on-site medical cover, delivering first line assessment, routine and emergency care, supporting consultants, responding to deteriorating patients, and acting as the hospital’s immediate medical presence. The service also had an additional RMO to support critical care and was available for support when needed. The RMO reported having positive working relationships with consultants and there was clear escalation processes in place that enabled them to raise any concerns promptly.

Consultant surgeons and anaesthetists were subject to a full assessment through the practising privilege process. They were required to provide evidence of appraisal and re-validation. From the staff records reviewed, we saw that medical staff working or practicing under under practising privileges had completed their professional revalidation.

Surgical procedures and clinical decisions were carried out by doctors with appropriate seniority and speciality training. Patients were clear who the doctors involved in their treatment were.

Overnight and weekend medical cover was adequate. Admitting consultants reviewed their patients regularly, including at weekends, and were available 24/7 for advice or attendance when required, with peer cover arrangements in place when unavailable.

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 managed infection risks well. The service used systems to identify and prevent surgical site infections. Staff used equipment and control measures to protect patients, themselves, and others from infection. They kept equipment and the premises visibly clean.

Theatres and ward areas were visibly clean, free from clutter and had suitable furnishings which were clean and well-maintained. Patients spoke positively about the cleanliness of the theatre and ward and staff attention to good hygiene practices. The service achieved 100% in the hand hygiene audit and 99.5% compliance in the cleaning audit.

Staff cleaned equipment after patient contact and labelled equipment to show when it was last cleaned.

The theatre environment followed national guidance, with separate areas to enable flow from clean storage, preparation, through to an area for dirty equipment and waste management. There was storage for equipment including sterile packs, uniforms and linen. There was sufficient space for laying up theatre trolleys under a ventilation canopy, if required.

Surgical instrumentation was managed on site with additional off-site support for some instruments under a service level agreement, which involved the processing of items, delivery of these and collection after use for cleaning and sterilising.

The provider had an infection prevention and control (IPC) policy and supporting guidance that were accessible to staff. The providers guidelines reflected national Infection Prevention Control (IPC) guidance from Public Health England (PHE), and the Royal College of Surgeons. Staff had access to expertise in infection control as needed.

There was a programme of infection and prevention and control audits including for example, hand hygiene, waste management, catheter care, water testing and reducing surgical site infections.

The service performed well in local IPC audits. In the most recent audits, the scores showed compliance with infection prevention and control measures in all clinical areas, with all audits achieving over 98% compliance.

Staff used records and data to identify how well the service prevented infections. The service monitored surgical site infection (SSI) rates, which showed 100% compliance. From April 2025 to March 2026, there had been 21 incidents of surgical site infection which were mostly superficial. The SSIs were mostly related to orthopaedic surgery, general surgery and cardiothoracic surgery. Others were maxilla-facial surgery, dermatology, spinal, plastic surgery and gynaecology. The service had an overall SSI rate of 0.42% for hip arthroplasty and 0.4% for knee arthroplasty, which was below (better) the national average.

From April 2025 to March 2026, the service reported 0 cases of hospital acquired Methicillin-resistant Staphylococcus aureus (MRSA), Methicillin-sensitive Staphylococcus aureus (MSSA), E.Coli and Clostridium difficile (C.diff).

There were processes to enable staff to respond to infection prevention and control risks such as transmittable infections.

We saw staff were following infection control principles including compliant handwashing and the use of personal protective equipment (PPE) as outlined in the services PPE standard operating procedure.

Theatre procedures minimised the risk of cross-infection, and staff followed best practice in the treatment and care of patients.

The management of clean and used surgical equipment and the flow through theatre reduced the risk of cross contamination. Staff checked the condition of sterile packs before they were opened and prior to use.

There was appropriate testing of water outlets and air exchange systems in theatres.

Staff understood the process for managing spillage of body fluids both on the wards and in theatres.

Staff supported infection prevention and control measures by following the uniform policy. Nail varnish and jewellery was not worn, and staff in clinical areas were bare below their elbows to allow for full hand decontamination.

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

The service used systems and processes to safely prescribe, administer, record and store medicines.

Staff followed systems and processes to prescribe and administer medicines safely. We reviewed 5 prescription charts during assessment. Patients’ allergies were recorded on prescription charts in line with NICE guidance. Patients' regular medicines were prescribed with the route and frequency clearly documented, signed by the prescriber, and records showed no missed doses. In theatres, medicines were not drawn up in advance of operating lists

Doctors reviewed each patient’s medicines on admission and provided advice to patients and carers about any changes. A pharmacist was involved in patient medicines reviews.

The service had clear guidance for staff about the safe use of antibiotics and opiates (controlled drugs).

The service supported and encouraged patients who were able and wished to self-administer their medicines.

Staff completed medicines records accurately and kept them up to date. There were accurate records of medicines administered in the operating theatre, recovery and wards.

Medicines including intravenous fluids were in date and stored in line with local and provider policy and reduced the risk of misuse and errors. Keys to the controlled drug cupboard were held by the nurse in charge of the ward. In the operating theatres there were separate medicines cupboards for each room. All medicines and intravenous medicines observed were in date and stored appropriately. Medicines were stored appropriately in the clinical room and fridges at the right temperature. Staff completed daily checks of ambient and fridge temperatures where medicines were stored.

There was effective governance of medicines, for example, the service undertook several medicines management audits including drug chart audit, controlled drugs register audit, storage and security of controlled drugs audit and storage and secure of medicines audits. Staff achieved 97% compliance in the medicines management audit, which was better than the provider’s 90% target.

Staff followed national practice to check patients had the correct medicines when they were admitted, discharged or they moved between services.

Staff learned from safety alerts and incidents to improve practice. There was a review of medicines errors and steps to prevent recurrence.

There was access to medicines needed in an emergency or at short notice at night and at the weekend.

There was sufficient equipment such as intravenous, subcutaneous, and self-administration pumps to allow the correct management of patients’ medicines.

Oxygen was prescribed when used. Air outlets were capped to prevent air being administered instead of oxygen.