Woodthorpe 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. We also checked people’s liberty was protected where this was in their best interests and in line with legislation.

This was the first assessment of this assessment service group. This key question has been rated good. This meant people were safe and protected from avoidable harm.

This service scored 78 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Score: 4

The service had a strong proactive and positive culture of safety, based on openness and complete honesty. Staff actively listened to concerns about safety and thoroughly investigated and reported safety events. Lessons were always learnt to continually identify and embed good practice.

Staff we spoke with all told us they knew how to raise incidents and concerns, and they did this as needed, leaders encouraged them to report everything no matter how minor if they felt they should do so. The endoscopy service sat within surgery, the service was an outlier for reporting incidents within the hospital group, but leaders saw this as a positive as every potential incident was reported.

Incidents were reported through an online incident management system which all staff had access to. Staff told us incidents were investigated in a timely way. Incidents initially had a rapid review to see if there was any immediate learning which could be implemented. We saw evidence that duty of candour was followed.

All newly reported incidents were discussed at a patient safety incident review group (PSIRG) on a weekly basis. This weekly meeting allowed representatives from different areas of the hospital, for example theatre staff and outpatients staff, to discuss incidents holistically and see where learning was required. Anyone could attend these meetings to discuss incidents; however, it was mandatory to have someone attend from each area. As part of the inspection process, we attended a PSIRG meeting and saw good discussions of patient safety incidents, learning being identified and clear actions recorded and assigned to staff. Duty of candour was also checked at these meetings.

Learning was shared across all areas of the hospital through team meetings and lessons learnt templates. Learning was also shared with other hospitals in the group.

Score: 3

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.

The service provided procedures for both private patients and NHS patients. NHS patients came via referrals for procedures from GPs, these were either accepted or rejected. If the patient did not meet the criteria for a procedure to be done safely, they were referred to an appropriate hospital or contact was made with the GP.

The service had clear inclusion and exclusion criteria, if a patient had some risk factors, they would be discussed at a complex case meeting to make a final decision. Patients were not booked in for any procedures until it was deemed safe to do so.

The service had clear parameters in place for when a patient would need to be transferred to a hospital in case of an emergency. The endoscopy team had its own separate pathway for patients with procedure or post procedure complications in place.

In line with Joint Advisory Group on GI Endoscopy (JAG) accreditation guidance the endoscopist and practitioners met before each list to identify any potential risks or issues. A pre- and post-procedure safety checklist was used for each endoscopy list.

Score: 3

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.

The service had a ‘safeguarding adults at risk of abuse and neglect’ policy which provided guidance to staff on ensuring the safety and well-being of its patients

Staff received training specific for their role on how to recognise and report abuse and understood how to apply it and to protect people from abuse. The service worked well with other agencies to do so.

Staff told us they followed the safeguarding guidelines and had attended safeguarding training, which was part of their annual mandatory training requirement.

Staff knew how to make a safeguarding referral, had a good understanding of when they would need to report safeguarding issues and who to inform if they had concerns.

Staff were able to describe situations, which would prompt a safeguarding concern and lead to a referral being made.

People were given the opportunity to raise any concerns, confidentially with staff when attending the hospital for treatment, or in their own home or by contacting them by telephone.

Data for March 2025 showed 100% compliance for safeguarding adults level 1, 2 and 3, and for safeguarding children level 1 and 2.

Score: 3

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.

At the preoperative stage endoscopy patients had a comprehensive appointment to discuss risk factors, such as medication or falls, and plan accordingly for both before and after surgery. We observed staff have open conversations with patients allowing them to understand and manage any additional risks associated with their procedures.

Patients told us staff were supportive throughout the process, and they felt their risks were managed well.

Score: 3

The service detected and controlled potential risks in the care environment. Staff made sure equipment, facilities and technology supported the delivery of safe care.

Throughout the assessment we observed that the environment was clean, tidy and well maintained throughout. There was one small procedure room which was fully compliant. Regular audits of the environment were undertaken.

In line with Joint Advisory Group on GI Endoscopy (JAG) accreditation guidance all areas were well maintained and support efficient patient flow and ergonomic and efficient working. Access to the area was restricted as appropriate.

Staff had access to appropriate equipment in both theatres and the recovery area for endoscopy. Staff could order specialised kit if needed. We checked electrical testing dates, and all equipment was in date. Consumables checked were all in date.

We saw daily checks of all equipment had taken place. Appropriate resuscitation equipment was available and checked accordingly in the endoscopy department.

Score: 3

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 was appropriately staffed throughout the whole process. Staffing levels were reviewed daily. There were full time staff within the department. The endoscopy theatre was appropriately staffed during the procedures we reviewed.

Staff had access to the appropriate support from leaders and management at the service. Staff told us that all new staff would have an induction, during this time they were supernumerary, and the induction would be tailored to meet their needs depending upon previous experience.

The service provided appropriate mandatory training for their staff, including basic life support and intermediate life support. Endoscopy staff mandatory training completion was 94.6%.

Whilst on inspection, we observed staff all working well together. Staff told us they always worked well together to meet people's individual needs.

Score: 3

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 facilities and environment supported service delivery and met both the Joint Advisory Group on GI Endoscopy (JAG) and Health Technical Memorandum (HTM) requirements for ventilation and decontamination. HTM 03-01 outlines ventilation requirements for healthcare premises, focusing on maintaining a safe and comfortable environment for patients and staff, particularly in areas dealing with airborne infection risks.

Staff ensured infection and prevention control measures were in place and any concerns were escalated when appropriate. Staff ensured that if there were concerns these were managed daily.

Staff had access to IPC policies and guidance.

All departments, including waiting areas and corridors, were visibly clean during the inspection. Hand gel was available at each doorway. Housekeeping staff were active throughout the ward areas. Staff cleaned equipment appropriately between use. Staff had access to appropriate personal protective equipment (PPE).

The hospital had a named IPC lead. The IPC lead dealt with day-to-day issues across the hospital and had links within all the departments. The IPC lead also carried out additional tasks like training with the housekeeping department, including representatives.

Staff carried out several IPC audits across the department. These audits included hand hygiene, sharps bin and surgical site infections. Results were mostly positive and when improvements were needed there were clear actions in place.

Score: 3

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.

Controlled drugs were stored and signed out correctly. Whilst on the assessment we checked medicines and all were within date. Fridge and room temperatures were monitored. Pharmacy came and regularly topped up medicines.

A resuscitation trolley was available on the endoscopy unit and was checked routinely by staff. Staff knew where this was in the event of an emergency. We checked the resuscitation trolley whilst on the assessment, and it was in date and regular daily and monthly record checks were seen.

Medicine incidents were reported using an online logging system, so staff could learn from them, and these could be investigated.

The service had a medicines audit cycle covering all areas of medicines management. When issues were found, action plans were developed, and changes were made as a result.