The Westbourne Centre

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 found safety was a priority across the service, supported by an open and collaborative culture. Processes were established to identify and respond to deteriorating patients in theatres and recovery areas. Staff completed surgical safety checks before procedures to ensure the correct patient received the correct operation. Medicines were managed safely, and patients were protected from abuse, neglect and discrimination. Staff sought informed consent where possible and, when patients lacked capacity, made decisions in their best interests with appropriate involvement from those close to them.

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to good. Patients 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. 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.

Managers investigated incidents and complaints and took prompt action where required. Incidents were recorded on a central log, including actions and outcomes. During the six-month reporting period, 24 incidents were reported in theatres. Most incidents were no-harm events, and there were no incidents resulting in moderate, major or serious harm. Lessons learned were used to improve care. For example, following a patient safety incident involving a post-operative haematoma (a build-up of blood after surgery), the service completed a structured review which identified learning around reinforcing patient education on recognising signs of complications and seeking timely medical advice.

The service promoted a positive culture of safety based on openness and honesty. Staff felt able to raise concerns and discuss incidents openly. Staff told us learning from incidents, complaints and debriefs were shared through team huddles, governance and departmental meetings and Medical Advisory Committee meetings. For example, following a procedure, staff identified during a debrief that rotating the operating table between procedures was quicker and more effective than moving equipment attached to the table from one side to the other. This learning was subsequently adopted as standard practice.

Patients and staff were encouraged and supported to raise concerns. They felt confident concerns would be taken seriously and responded to with compassion and understanding. Verbal complaints were logged when received. A nurse contacted all patients following surgery and, where required, made further calls to monitor their recovery and wellbeing.

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 were prioritised throughout patient’s care pathway. Information was shared appropriately with relevant healthcare professionals, including GPs and the operating hospital, to support safe and effective care. Patients were seen by their consultant throughout their surgical journey, promoting continuity of care.

Risks were identified, assessed and managed throughout the surgical pathway. Admission criteria were aligned with hospital requirements and supported staff to determine whether patients were suitable to proceed with treatment. Patients completed a pre-operative medical questionnaire, which was reviewed and shared with the hospital in advance of surgery. A World Health Organisation (WHO) Surgical Safety Checklist was completed to help minimise risks and promote patient safety. Where risks or underlying health conditions were identified, appropriate action could be taken, including seeking further assessment or delaying treatment.

Patient records were maintained electronically and stored securely. Staff had timely access to information required to support safe care and effective communication with partner organisations.

The service actively sought feedback from patients and staff. Patients received a follow-up call after their procedure to monitor recovery, address any concerns and gather feedback on their experience of care and aftercare. Patients were provided with a dedicated contact number on discharge, enabling them to access advice and support from the provider until 8pm. After this time, patients could contact an affiliated hospital for clinical advice and support overnight. Arrangements were in place to ensure continuity of care, with the affiliated hospital and provider shared information regarding any patient contacts or concerns received outside the provider's operating hours through email communication or telephone handovers the following day. This ensured patient concerns were responded to appropriately and that relevant information was communicated effectively between services to support safe ongoing 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.

All staff received safeguarding training appropriate to their role and knew how to recognise and report concerns. Non-clinical staff were trained to Level 1 safeguarding. Clinical support workers and healthcare assistants were trained to Level 2 safeguarding. Registered nurses, operating department practitioners (ODPs) and consultants were trained to Level 3 safeguarding, in line with current intercollegiate safeguarding guidance for registered healthcare professionals. The safeguarding lead had completed advanced safeguarding training appropriate to their role. Staff understood safeguarding processes and knew how to escalate concerns when required.

As of June 2026, compliance with safeguarding training was high. Safeguarding Adults Level 1 compliance was 100% and Level 2 compliance was 98%. Safeguarding Children Level 1 and Level 2 compliance were both 98%, and Level 3 compliance was 100%.

The service had up-to-date safeguarding policies aligned with national guidance for adults and children. Staff knew how to recognise safeguarding concerns, make referrals, escalate concerns appropriately, and access specialist safeguarding advice when required.

Safeguarding was considered following incidents, with referrals and external agency involvement sought where necessary. Staff demonstrated a good understanding of identifying adults and children at risk and protecting patients from abuse, harassment, and discrimination, including those with protected characteristics under the Equality Act 2010.

The Registered Manager maintained oversight of safeguarding activity within the service. Discharge and follow-up arrangements were managed safely, and patients told us they knew what to expect following discharge and when they would next be reviewed by a nurse or doctor.

Staff followed safe procedures, and patients told us they felt safe and well supported whilst receiving care. 

The service worked with patients to understand and manage risks by thinking holistically. Staff provided care to meet patient’s needs which was safe, supportive and enabled patient to do the things that mattered to them.

Patients were actively involved in managing risks associated with their care and treatment. Staff completed risk assessments throughout the patient journey, including during consultations, pre-operative assessments, procedures and follow-up reviews. Patients provided information about their medical history, current medicines, allergies and GP details to support safe decision-making. For patients undergoing major and minor surgery, nurses completed comprehensive pre-operative assessments, which included consideration of both physical and mental health needs to ensure patients were suitable for treatment.

The service had clear admission criteria for surgical procedures, and staff assessed patients against these criteria to ensure treatment was appropriate and risks were minimised. Processes were in place to verify patients' age and identity.

Patients received comprehensive information about the risks, benefits and expected outcomes of treatment through consultations and pre-operative information provided in a range of formats. This supported patients to make informed decisions about their care. Patients were also provided with a 24-hour contact number and had access to clinical advice and support before and after surgery.

The service had clear arrangements in place for the management and escalation of patients whose condition deteriorated or who experienced serious complications. Staff followed a transfer procedure for critically ill patients, which included consultant-led decision-making, risk assessment, liaison with local NHS providers and critical care services, and appropriate clinical support during transfer. This supported timely access to higher levels of care when required.

We saw evidence that patients were supported to raise concerns following treatment and had access to timely clinical advice when required. For example, following routine post-operative follow-up, staff responded promptly to a patient who reported pain and swelling after surgery. Clinical advice was provided, a repeat telephone review was arranged, and the patient was escalated for urgent face-to-face assessment and consultant review. This resulted in the timely identification and treatment of a post-operative haematoma (a build-up of blood after surgery).

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 supported the safe delivery of care and treatment. Staff were trained in the safe use of equipment and the management and disposal of different types of waste.

The environment was designed in line with relevant national guidance. Areas requiring restricted access were secure and protected patients, with swipe card entry systems in place. Fire safety equipment was available, regularly serviced and maintained, and fire exits were clearly marked and free from obstruction.

Suitable equipment was available to meet patients' needs and support the delivery of care. Staff used equipment appropriately and completed routine safety checks of specialist equipment. Resuscitation equipment was readily accessible within theatre areas and maintained to ensure it was fit for purpose. Specialist equipment used in operating theatres was managed in accordance with national guidance and regulatory requirements.

Leaders maintained oversight of equipment and environmental safety through regular audits, monitoring and weekly engineering safety checks. These checks had identified fire safety concerns requiring door replacements, and prompt action had been taken to address this. Leaders also monitored ageing equipment through maintenance and replacement programmes. Staff told us they had sufficient equipment to carry out their roles safely, and effective arrangements were in place to repair or replace faulty or missing equipment.

The service had suitable facilities to support patients' relatives and carers when required.

Clinical waste was managed safely throughout the service. Waste was appropriately segregated, stored and labelled in line with policy. Sharps were managed safely, reducing the risk of injury to staff and others. Hazardous substances were stored securely, and staff had access to relevant safety information.

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.

New staff completed a role-specific induction and bank staff received a local induction before working in the service. Managers supported staff through appraisal, supervision and training opportunities. Appraisal compliance was 94.8% in June 2026. Performance Development Reviews (PDRs) were used to identify development needs and support staff to access clinical, leadership and professional development training.

The service had low vacancy rates, with no vacancies reported in March or April 2026 and one vacancy in May 2026. The vacancy related to a non-clinical operational role and the service reported no clinical vacancies. The service was supported by a regular and flexible bank workforce.

Staff turnover was 9.13% in March 2026 and 11.41% in April and May 2026. Sickness rates were 4.8% in March and April 2026 and 4.4% in May 2026. Leaders told us the sickness rate related to an operational staff member on long-term sickness absence.

Managers minimised the use of agency staff and used staff familiar with the service wherever possible. Staff told us they felt staffing levels were safe and that they were able to take appropriate breaks during their shifts.

The service supported staff to maintain and develop their skills through mandatory, specialist and role-specific training.

Consultant surgeons and anaesthetists were subject to a practising privileges process, including appraisal and revalidation checks, and care was delivered by appropriately qualified and experienced medical staff. Patients knew which doctors were involved in their care.

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 prevention and control (IPC) risks well. Systems were in place to identify, monitor and prevent healthcare-associated infections, including surgical site infections. Staff used appropriate equipment and control measures to protect patients, visitors and themselves from infection. Equipment and premises were visibly clean, clutter free and well maintained.

Clinical and theatre areas were visibly clean and well maintained. The theatre environment supported the safe flow of clean and used equipment, reducing the risk of cross-contamination. There were appropriate arrangements for the storage of sterile supplies, linen and equipment, and for the management of waste.

Staff had access to IPC policies and guidance aligned with national standards. The service had a dedicated IPC link nurse with protected time to fulfil the role, access to specialist microbiology support and an IPC Committee which monitored IPC performance, risks and actions through established governance processes. Staff completed mandatory infection prevention and control training, with compliance rates in June 2026 of 94% for Aseptic Non-Touch Technique (ANTT), 89% for IPC Level 2, and 90.9% for Hand Hygiene.

The service had attained gold level ANTT® (Aseptic Non-Touch Technique) Accreditation, awarded in March 2026 and valid until March 2029, providing independent assurance of high standards of aseptic practice and patient protection.

The service undertook regular IPC audits to monitor compliance. Monthly theatre hand hygiene audits completed in March, April and May 2026 achieved 100% compliance against the '5 Moments for Hand Hygiene' standard. A whole-hospital IPC governance and assurance audit completed in September 2025 and an IPC environment and infrastructure audit completed in December 2025 also achieved 100% compliance.

Environmental cleanliness was monitored through internal and external audits. External audits completed in March 2026 and May 2026 identified issues relating to high-level dusting and dust on radiator covers. The provider had implemented and completed an action plan to address these findings.

We observed staff following IPC principles, including effective hand hygiene, appropriate use of personal protective equipment and compliance with the uniform policy. Staff working in clinical areas were bare below the elbows and did not wear nail varnish or hand jewellery. Staff cleaned equipment after use, checked sterile equipment before use and understood procedures for managing bodily fluid spillages and patients with transmissible infections.

Appropriate testing and monitoring of water outlets and theatre ventilation systems were in place, helping to ensure patients received care in a clean, safe and hygienic environment.

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 had effective systems and processes to support the safe prescribing, administration, recording and storage of medicines.

Staff followed systems and processes to administer medicines safely. Medicines were not routinely drawn up in advance of theatre lists, reducing the risk of error.

Medical staff reviewed patients' medicines on admission and provided advice to patients and carers about changes to treatment.

Medicines records, including records of medicines administered in theatre and recovery, were accurate, complete and up to date.

Medicines, including intravenous fluids, were stored securely in line with local policy. Staff followed national guidance to ensure patients received the correct medicines on admission, discharge and transfer between services.

Staff learned from medicines-related incidents and safety alerts. Medicines optimisation was supported through pharmacy audit and governance processes that monitored medicines management, controlled drugs governance and compliance with medicines safety requirements. Audit findings were used to improve practice.

Staff had access to medicines required in an emergency, at short notice and during weekends. Sufficient equipment was available to support the safe management and administration of medicines.

Oxygen was prescribed appropriately when required. Nursing staff were required to complete mandatory medical gas safety training, with compliance recorded at 84% in June 2026.