The New Victoria Hospital

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• 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

This means we looked for evidence that people were protected from abuse and avoidable harm.

The service had systems and processes to provide good care for patients. Leaders investigated incidents and shared lessons learned with the whole team. Leaders encouraged a positive culture of safety based on honesty. Staff understood how to protect patients from abuse and recognised incidents and reported them appropriately. Leaders made sure there were enough competent staff to keep patients safe. The environment was clean, and infection risks were well managed. At our last assessment, we rated this key question good. At this assessment, the rating has remained good.

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.

We scored the service as 3. The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Safety events were reported and investigated, and learning from incidents was used to promote good practice. Systems were in place to support managers in investigating incidents relating to the Outpatient Department (OPD).

Between March 2025 and April 2026, there were 1,138 incidents reported across the hospital. During the same period, 292 incidents were recorded within the OPD. The most common category related to pathology, accounting for 174 incidents, which included delayed or missing results and insufficient samples.

During the assessment, OPD staff told us they had taken action to address pathology‑related issues through engagement with the contracted NHS partnership that provided this service. This included monthly governance and incident review meetings between the pathology provider and the OPD. Our review of documents indicated there had been no incidents requiring the duty of candour. Staff we spoke with demonstrated an understanding of duty of candour, and this was reflected in the service’s policy. Policies and procedures were up to date, referenced relevant guidelines and were appropriate for the service.

Incidents were reviewed through a monthly Integrated Governance Committee, which analysed themes and trends and shared learning. For example, the committee reviewed the top 3 incident categories each month, monitored changes compared to previous months, tracked incidents still under investigation, and agreed follow‑up actions.

The service used a board assurance risk framework that allowed them to benchmark services; this was monitored through the integrated governance and risk committee, which held monthly meetings. The Heads of Department and members of the executive team attended these monthly meetings, where they reviewed clinical incidents and considered local, national and group‑wide updates. They also checked for relevant national guidance and ensured changes to practice were implemented where required.

Reporting processes ensured managers had effective oversight of incidents and supported the timely submission of statutory notifications. Staff told us there was a positive reporting culture, which encouraged openness, shared learning and effective risk management. Learning from incidents was shared through governance processes and team forums, including daily safety huddles.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The service worked with people and their partners to ensure care was planned, coordinated and delivered safely. Systems were in place to manage, monitor and assure safety, and to support continuity of care within the service and when people were referred to other services.

There were appropriate policies and procedures to guide staff when transferring patients. This included arrangements for clinically unwell adults and children, as well as non‑emergency transfers involving children.

Leaders and staff told us there were strong working relationships between clinical and non‑clinical teams. Consultants, nurses and healthcare assistants in the Outpatient Department (OPD) worked well together. Staff described patients’ journeys through pre‑assessment for patients undergoing surgery under general anaesthetic, and other OPD specialities, and explained how continuity of care was maintained when patients moved between services, such as from pre‑assessment to surgery.

We saw evidence of effective checks and handovers within the OPD team, including during daily morning huddles. Information was also shared at the daily hospital‑wide huddle, which was attended by Heads of Department, including senior OPD staff. We reviewed 10 sets of electronic and paper patient records and found these were accurate and up to date.

Staff told us that patients attending OPD for procedures were always asked for their consent and provided with clear information about their treatment. This was confirmed through our review of patient records.

Patients’ welfare was monitored throughout OPD appointments, and any concerns were escalated to the treating consultant as needed. For example, patients attending pre‑assessment were contacted by phone or offered face‑to‑face appointments to support completion of health questionnaires and address any missing information. Where required, concerns were shared with the pre‑assessment anaesthetist, inpatient consultants or the patient’s GP.

Referrers used systems to ensure relevant patient information was shared appropriately. We saw evidence of effective handovers between teams. The service had policies and guidance for emergency transfers to NHS hospitals, which included consultant‑to‑consultant referral, formal handover to receiving teams, and ensuring necessary equipment and medicines accompanied the patient. Staff consistently checked patients’ identities to ensure the correct care was provided.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They 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 worked with people to improve their health while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. Staff made sure they shared any concerns quickly and appropriately.

There was up-to-date guidance in place, including safeguarding policies, flowcharts and contact lists. This meant staff could report concerns and ensure appropriate actions were taken quickly. Staff we spoke with knew how to recognise and report concerns. They could explain the process to raise a safeguarding referral and were confident that the right action would be taken. For example, in an incident involving safeguarding disclosure within the OPD where a safeguarding concern was raised by a relative during a paediatric consultation, this information was appropriately shared, with an appropriate safeguarding referral raised.

Staff understood the service’s processes for gaining patient consent and how to support people who may not be able to provide consent. They were suitably trained and knew about the Mental Capacity Act (2005). Patients told us they felt safe within the service and found staff approachable and caring.

Data showed OPD nursing and support staff had completed Level 2 safeguarding training for both adults and children. This is in accordance with the New Victoria Hospital policy, which specifies that all non-clinical and clinical staff who have any contact with children, young people and/or parents/carers should have a level. The hospital’s children safeguarding policy also stipulated that level 3 safeguarding training is required by all paediatric nurses and all clinical staff where there are safeguarding/child protection concerns.

Children and young people (CYP) attending OPD services were seen during adult clinic times and within the same OPD areas. Arrangements were in place to support safety, including a staffed reception available 24 hours a day, seven days a week, and CCTV coverage both internally and externally. Children were expected to be accompanied by a parent or carer at all times while on site, as outlined in the “your child’s hospital admission booklet.” Staff told us that 1:1 nursing supervision could be arranged for all patient's if required. Signage was also present in OPD areas, reminding parents and carers to supervise their children.

We scored the service as 3. The evidence showed a good standard. 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.

Staff carried out clinical risk assessments to support patient safety during treatment. We observed staff completing a modified WHO checklist. Guidance was in place to support discussions with patients about the risks and benefits of treatment.

Staff told us these discussions took place at initial outpatient appointments and were revisited when obtaining consent. We observed this during clinic. Patients were given opportunities to ask questions throughout their care. Patients we spoke with said procedures were clearly explained, including risks and benefits, and that they felt able to ask questions and make informed decisions.

We scored the service as 3. The evidence showed a good standard. The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

We were told the hospital’s maintenance compliance schedule was largely manual and had been recognised as an area for improvement, which had been raised with Bupa. Work was underway to transition compliance monitoring to a centralised compliance system. We were told the transition to centralised systems for fire and water safety had already started. The anticipated timescales for this roll-out were not shared. The Medical Gas Pipeline Systems within 2 clinical treatment rooms did not comply with Medicines and Healthcare products Regulatory Agency (MHRA) guidelines, published in 2006 and updated in 2024. However, when we informed the hospital’s leaders about this issue, immediate action was taken to ensure the systems were fully compliant with MRHA regulations before the inspection team left the site.

Staff could access appropriate emergency equipment as needed. We saw that a resuscitation trolley was positioned in an easily accessible place in the corridor within the Outpatient department (OPD). We checked the trolley, and all items were in date. We saw evidence that staff conducted daily and weekly checks and these corresponded with records in the audit book. Staff were clear about their responsibilities regarding premises and equipment. The right equipment was available and used to deliver care and treatment that was suitable for the intended purpose. We saw that equipment was stored securely and used properly to support people to stay safe and minimise risk. Supplies and consumables were stored appropriately and were within their use by dates. Fridge temperatures were checked regularly. We saw that OPD equipment was regularly checked for serviceability, and we observed that testing of electrical equipment was up to date. Staff told us they could raise any concerns about the site or equipment at daily meetings or report issues directly to their managers, who would address these promptly. These systems were maintained by a designated member of the OPD leadership team.

Fire exits and doors were observed to be free from obstruction, clearly marked, and staff knew the correct procedures to follow in an emergency. The fire drills were conducted on a weekly basis, and there were designated fire marshals within the department.

There was a policy in place to manage the risks of Legionella. This ensured the relevant mandatory water flushing checks were completed by housing keeping staff, the risks associated with it were also identified within the corporate risk register, with an action plan developed which mitigated identified risks.

We scored the service as 3. The evidence showed a good standard. The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Leaders ensured recruitment, disciplinary and ongoing review processes were safe, fair and were regularly checked to ensure there was no disadvantage based on any specific protected equality characteristic in accordance with local policy.

The Outpatient Department (OPD) had a full team, including nursing staff, healthcare assistants and other healthcare practitioners such as a pathology coordinator. There was also input from a specialist breast care nurse. From April 2025 until March 2026, the turnover rate for all direct staff varied from lowest at 0% for most months to the highest figure of 10% in February 2026. For bank staff utilised between April 2025 – March 2026, the total was divided by role, for example, healthcare assistants (HCAs) bank staff usage rates were 19%, staff nurses 15% and sisters were 0%. Overall, OPD agency staff use was 5% for the same period. Staff sickness rates varied by role, for example, HCA’s sickness rates were 13%, staff nurses 3% and junior sisters were 2%. The causes for the figures were unclear, as well as the service plans to address these.

The staffing was scheduled a month in advance. The hospital did not use electronic rostering; it used a ‘dynamic’ staffing model, which sought to respond to activity and clinical need. The OPD used departmental knowledge such as block plans for clinics and interventional areas, previous activity data and consultant leave notifications when planning staff rotas. Lower activity during holidays, due to patient choice and consultant availability, was described as responsive to patients' choice, and planned service delivery to suit patients’ schedules. The service used regular bank staff to cover increased activity. Data showed that staffing numbers and skills were appropriate for the OPD. Mandatory training compliance figures for OPD staff showed a 90.5% compliance for senior nursing and a total of 94% for health care assistants. The departmental training compliance was discussed at the monthly interdepartmental governance meeting, which allowed heads of departments to address any gaps in training. Additionally, training could be addressed locally at the OPD staff meetings, via emails and daily huddles. There was a dedicated area of the hospital’s internal IT system which alerted staff to training needs, including any training compliance issues with things like due dates for e-learning programmes, using a ‘Red, or Green’ flagging system.

Data showed 100% of the 6 allocated OPD staff Level 3 had completed safeguarding training for both adults and children. Whereas 85% of the 15 allocated staff had completed Level 2 safeguarding training for adults and 76% of the 17 allocated staff had completed Level 2 safeguarding training for children. New Victoria Hospital policy specifies ‘‘all non-clinical and clinical staff who have any contact with children, young people and/or parents/carers should have a level 2’ safeguarding training for children. However, this included nursing staff who worked directly with Children and Young People (CYP), even when direct supervision of a paediatric nurse was not available within the OPD where no safeguarding concerns were raised. The Intercollegiate Document ‘Safeguarding children and young people: roles and competencies for health care staff’ published by the Royal College of Paediatrics and Child Health (RCPCH), which is nationally recognised best practice, recommends level 3 safeguarding for clinicians who work directly with CYP, in roles involving assessing health needs and contributing to the evaluation of parenting capacity. However, mitigations in place included that all non-paediatric-qualified staff working with CYPs in outpatient clinics had undertaken additional training and completed competencies with the CYP Lead. In addition, the hospital had ensured there was paediatric nurse cover allocated to the OPD when CYP were being treated within clinics before the end of the assessment visit.

Consultants with practising privileges were permitted to work in the hospital, including in the OPD. The process meant successful applicants had their applications submitted to the medical advisory committee (MAC) as part of the practising privileges (PP) review team, presented to the PP corporate governance committee and approved. The criterion followed meant applications were assessed according to their completion of NHS work and activity that was commercially viable. Once awarded, PP were subject to internal monitoring to ensure the consultants were compliant with the relevant employment and professional standards as per PP requirements, such as evidence of appraisal, relevant insurance and mandatory training. Leaders told us that, although rare, consultants could have their PP’s suspended if they failed to adhere to PP requirements.

We scored the service as 3. The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The service had up-to-date infection prevention and control (IPC) policies which used national guidance and had audit processes in place. IPC concerns could also be escalated through the IPC Lead nurse, the Director of Infection Prevention and Control and the consultant microbiologist.

We observed the outpatient department (OPD) to be clean, tidy and well maintained. Staff were bare below the elbows, practised hand hygiene between patients, and cleaned equipment after use. ‘I am clean’ stickers were used to indicate equipment was ready for use. Hand sanitiser and handwashing facilities were readily available, and consulting rooms were well stocked with appropriate personal protective equipment (PPE). We observed staff using PPE appropriately in line with guidance, including gloves and aprons where indicated.

We saw PPE was readily available and well stocked across OPD clinical areas. IPC signage and guidance were also visible in clinical areas.

Staff demonstrated awareness of current IPC guidance and described how concerns could be escalated locally or through link practitioners. Single-use privacy curtains were in date, and flooring in clinical areas adhered to regulatory standards. Sharps were managed and labelled in line with national guidance.

IPC audits were completed regularly, with evidence of compliance with annual and biannual targets. Dedicated local OPD IPC link practitioners, with access to specialist consultant microbiology advice and an IPC lead nurse supported practice within the OPD. A housekeeping team-maintained cleanliness, and we saw cleaning records, including for toilets, were completed. Equipment decontamination arrangements were in place, including external sterilisation services and on-site flexible endoscope decontamination.

Patients told us the environment was clean and reported seeing staff follow good hand hygiene practices.

We scored the service as 3. The evidence showed a good standard. The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

Outpatient Department (OPD) staff did not prescribe medicines, as prescribing took place during consultations. Patients who had questions or concerns about their medicines were supported to discuss these with their consultant or the hospital’s dedicated pharmacy team.

Medicines were stored securely and safely. Staff monitored room and refrigerator temperatures in all areas where medicines were stored, and records showed medicines were kept within the required temperature ranges. We reviewed a sample of medicines stored in the OPD emergency trolley, the minor operations treatment room and the gynaecology room. All medicines we checked were stored appropriately and were within their expiry dates.

Staff followed comprehensive medicines policies and guidance, including those relating to controlled drugs. The hospital's medicine policies were in date, regularly reviewed and aligned to national guidelines. The wider service had arrangements in place to ensure patients could access the medicines they needed. This included guidance on the use and management of patients’ own controlled drugs.

A medication safety officer oversaw medicines governance and provided assurance through audits, monitoring issues and reviewing staff compliance with mandatory medicines training, including safe handling and administration. Information on medication issues such as incidents, audits and learning was reported to the hospital’s monthly governance meetings.