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.

At our last inspection we rated this key question good. At this assessment the rating has remained 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 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 meeting to discuss incidents, however it was mandatory to have someone attend from each area. As part of the assessment process, we attended a PSIRG meetings 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 had been identified in relation to medicines errors, there had been no harm identified but as a few had happened close together some learning support was given to staff. Another incident had occurred involving a patient that had a cardiac arrest and had been resuscitated successfully, whilst the outcome was positive there was learning identified for the resuscitation team following the debrief and this was shared with them.

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.

Woodthorpe were engaged in system wide learning. The service participated in learning groups across the integrated care system. The service had representation at the Nottinghamshire system wide tissue viability group, infection prevention control group and falls prevention 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.

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 their 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 children level 1 and 2 and safeguarding adults level 1, 2 and 3 was 100% compliance.

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 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 all areas of the hospital. Safety was maintained, with areas such as the Control of Substances Hazardous to Health (COSHH) cupboard being locked. Regular audits of the environment were undertaken.

The wards were accessible and spacious. Patients had private rooms with accessible ensuite wet room facilities.

Staff had access to appropriate equipment in both theatres and wards. Staff in theatres could order specialised kit if needed. We checked electrical testing dates on equipment and apart from 2 stickers, 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 each area we visited.

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 all areas. Staffing levels were reviewed daily. As of April 2025, the service had 2 vacancies in theatres. Theatres were appropriately staff 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. Ward staff mandatory training completion was 91.8% and theatre staff mandatory training completion was 94.8%.

Whilst on assessment, 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 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 all areas. Staffing levels were reviewed daily. As of April 2025, the service had 2 vacancies in theatres. Theatres were appropriately staff 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. Ward staff mandatory training completion was 91.8% and theatre staff mandatory training completion was 94.8%.

Whilst on assessment, 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.

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 Infection prevention and control (IPC) policies and guidance.

All departments, including waiting areas and corridors, were visibly clean during the assessment. 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 service had recently changed antibiotics for joint patients, which reduced the risk to patients for a variety of co-morbidities. The IPC lead also carried out additional tasks like training with the housekeeping department, including representatives.

Staff carried out 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.

Resuscitation trolleys were available on wards and in theatres and checked routinely by staff in case they were needed for an emergency. Staff knew where these were located in the event of an emergency. We checked resuscitation trolleys whilst on the assessment, and they were all in date and regular daily and monthly record checks 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. As part of the assessment process we requested 6 months worth of audits. When issues were found, action plans were developed, and changes were made as a result. For example, in the most recent controlled drugs audit it was noted that an area for controlled drugs was needed, so this had been put in place.