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 previously inspected outpatients jointly with diagnostic imaging so we cannot compare our new ratings directly with previous ratings. This is the first assessment for this service. This key question has been rated good. This means that people were protected from abuse and avoidable harm.

The service was safe. People were safe because individual and environmental risks were assessed, and steps taken to reduce them. Risks were managed positively and did not restrict people's lifestyle choices unnecessarily. The service had procedures in place to protect people from potential abuse and unsafe care. There were sufficient numbers of staff with the necessary skills, experience and qualifications to meet people's needs and preference. People received their medicines on time and in a safe way. The environment was safe and well maintained. Good levels of infection prevention and control were maintained throughout the hospital.

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

There were clear and documented systems in place to ensure patient risks were identified and managed. These systems supported the safe delivery of care to patients.

The service worked with people, those close to them and healthcare partners to establish and maintain safe and effective treatment and care to eliminate risks and to ensure continuity of care.

The service provided procedures for both private and NHS patients. NHS patients were referred from the persons GP. Private patients could self-refer.

Information on how private patients could self-refer for treatment was available on the hospital website, which also included methods of payments for various procedures.

The service had an inclusion and exclusion criteria, if a patient had certain risk factors, they would be assessed at a complex case meeting to make a final decision.

Risk factors included a number of various conditions, for example, high body mass index (BMI), elevated blood pressure and cardiovascular or renal complications.

We spoke with 2 private patients, who advised they had been assessed and received treatment quickly.

The service had a policy in place for when a patient would need to be transferred to a hospital in case of an emergency.

Services were designed to meet the needs of the population, and all patients were seen within 18 weeks of referral to the hospital.

Staff kept detailed records of patients’ care and treatment. Records were clear, up to date, stored securely and easily available to all staff providing care.

Outpatient services were offered up to six days a week. Monday to Friday clinics ran from 8am to 8pm, and on Saturdays, clinics ran from 8am to 4pm.

The service provided care and treatment based on national guidance and evidence-based practice.

The service had guidelines policies and procedures that were up to date and accessible to staff on the electronic intranet based on current guidance.

All members of the multidisciplinary team worked and interacted well with each other to enable a coordinated approach to the way in which care was delivered.

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 were able to describe situations, which would prompt a safeguarding concern and lead to a referral being made. However, there had been no safeguarding alerts for the last 6 months for the outpatients department and staff we spoke with could not remember when they last made a safeguarding referral.

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.

The hospital had a safeguarding lead; staff knew the name of the safeguarding lead and told us they could approach them for advice if they needed to.

People were given the opportunity to raise any concerns, confidentially with staff when attending the outpatient department for initial assessment or treatment.

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

Data for March 2025 showed 100% compliance for Safeguarding children level 1 and 2 and for Safeguarding adults level 3. Safeguarding adults level 1 and 2 was 92% compliance, against the service target of 90%.

Score: 3

Staff had clear guidance to follow should a patient’s condition deteriorate while they were in the outpatient department.

There was a clear process to check the identity of patients in the outpatient department, which staff were knowledgeable about. Reception staff were observed checking patients personal details when they entered the clinic providing a double check that they had the correct patient record.

The service protected patients from the risk of abuse and avoidable harm. Patients were risk assessed to ensure they were suitable for treatment at the hospital and staff monitored them appropriately during their stay.

We reviewed 6 risk assessments and saw they were all completed correctly.

We spoke with 5 patients during our assessment, all of them described regular and open conversations concerning their treatment and health. They told us they felt involved in the process of their treatment and that staff listened to any concerns they had and took them seriously

Staff made sure that people understood the care and treatment that was being provided

One person described their discussion with a staff member about the risk of their cataract procedure and how this had been discussed in-depth with them in language they could understand and how re-assuring this was.

Score: 3

During our assessment, we found the outpatients department clean and well maintained, with sufficient seating to accommodate all the patients who were attending. All clinic signs were clear, hazardous items were out of reach, and there were no sharp corners.

Access to clinical areas was through a swipe card system. This meant the area was secure and minimised the risk of unauthorised access.

Equipment was visibly clean. We saw labels on equipment with the last service date and review date. Staff we spoke with were clear on the procedure to follow if faulty or broken equipment was found. Broken or faulty items were removed from the clinic area to prevent further use.

We checked single use items in consulting rooms, and all were stored appropriately and were in date.

Facilities, equipment and technology were well-maintained and consistently supported staff to deliver safe and effective care.

Equipment used to deliver care was suitable for the intended purpose, it was stored securely and used properly and appropriately. For example, the resuscitation equipment was clean, well maintained and ready for use in an emergency.

Daily checks took place on the resuscitation trolleys to ensure the seal had not been broken. Logbooks showed staff had signed to indicate the resuscitation equipment had been checked and was safe and ready for use in an emergency. A further checklist was used to identify disposable items due to expire the following month. These were disposed of and replaced. Single-use items were sealed and in date. Checks of all contents in the resuscitation trolleys took place monthly.

Staff disposed of clinical waste safely. Sharps bins were correctly assembled and were not overfilled.

Clinical rooms had call bells for staff or patients to summon assistance, should a patient become unwell.

Specialised personal protective equipment was available for use when undertaking surgical procedures.

Score: 3

All new members of staff and volunteers underwent a structured and comprehensive induction training programme appropriate to their role.

The service had a mandatory training and competency framework; compliance was monitored through the service’s training database. All mandatory training and competencies were reviewed on a regular basis to ensure that they met current guidelines and procedures.

The service had enough staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. Managers regularly reviewed and adjusted staffing levels and skill mix.

Staffing levels were appropriate to meet the needs of patients. The service used a staffing tool to help hospital staff measure patient acuity and / or dependency to inform evidence-based decision making on staffing.

Managers gave all new staff a full induction tailored to their job role before they started work. There was a structured induction programme in place which all staff completed when they started work.

There was a procedure to check that nurses and other health care professionals maintained their registration with their professional bodies.

Staff at all levels received regular meaningful appraisals, which provided them with development and career opportunities as well as their own wellbeing and safety was supported. At the time of our assessment 100% of staff had completed their yearly appraisal.

Staff working within the outpatients department told us staffing levels were appropriate for them to provide good patient care.

We observed that staff were visible in all areas and did not appear to be rushed. Staff communicated well with each other to respond promptly to people's needs.

We spoke with 3 patients who told us there always appeared to be enough staff to provide good care. One person told us “they are really good here and are never too busy if I have a question or I am worried about something.”

Score: 3

The service-controlled infection risk well. Staff used equipment and control measures to protect patients, themselves and others from infection. They kept equipment visibly clean.

All areas of the hospital were observed to be visibly clean and tidy, including the reception and waiting area. Staff were observed to be following the service’s ‘bare below the elbows’ protocol. Hand gels were readily available in all areas of the hospital.

Staff followed infection control principles including the use of personal protective equipment (PPE), appropriately.

We saw staff regularly utilise the alcohol hand rubs in accordance with the World Health Organisation’s (WHO) ‘5 Moments for Hand Hygiene’. These guidelines are for all staff working within healthcare environments and define the key moments when staff should be performing hand hygiene in order to reduce risk of cross contamination between patients.

Score: 3

The service used systems and procedures to safely prescribe, administer, record and store medicine.

Processes were in place for the management medicines and safe storage. Staff completed regular checks of medicines in line with guidance.

Medicines in outpatients were stored in locked cupboards or fridges

Fridge and room temperatures were monitored and pharmacy regularly refilled medicines.

There was a pharmacy lead and pharmacy technician who had oversight of medicines. Patients were discharged with a minimal supply of medicines, the GP was then requested to take over prescribing to ensure oversight and continuity.

A pharmacy service was provided six days a week, Monday to Saturday.

Treatment rooms were clean and tidy with appropriate waste bins in each room.

The service had a clear drugs disposal process in place. We reviewed the records for this process and found they were accurate, and the practice was secure.

Patients requirement for pain relief were met appropriately during a procedure or investigation.

During our assessment, data showed the service had 87% compliance for all medicines administered in the outpatient clinics against the service target of 100%