The New Victoria 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. Leaders had systems for identifying and responding to deteriorating patients on the wards, in the operating theatre and recovery. People received treatment and care to reduce the risk of avoidable harm, such as pressure damage, blood clots or falls. There were safety processes arranged before surgical procedures and operations started, with staff working together to ensure the right patient had the correct operation. Medicines were managed safely. Patients were safe from neglect, abuse and discrimination. Patient’s gave informed consent prior to procedures and where they were unable to consent, those close to them were involved in decisions made in their best interests.

At our last assessment we rated this key question good. At this assessment the rating has remained 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.

We scored the service as 2. The evidence showed some shortfalls. 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. However, not all staff were up to date with mandatory training.

The service managed patient safety incidents well. Staff recognised and reported incidents and near misses. Managers investigated incidents and shared lessons learned with the whole team and the wider service through both team meetings and a digital messaging platform. When things went wrong, staff apologised and gave patients honest information and suitable support. Managers ensured actions from patient safety alerts were addressed and progress was monitored.

The service had a current incident reporting and reviewing policy, which reflected the providers and national guidance. Staff raised concerns and reported incidents and near misses in line with provider policy.

We saw evidence of incidents having been investigated, and sufficient action taken to reduce the risk of recurrence. We looked at the system for managing incidents which was electronic.

There had been no reported never events in the preceding year. Never Events are serious, preventable safety incidents which should not occur if the available preventative measures are followed. They include things like wrong site surgery or foreign objects left in a person’s body after an operation.

Staff were able to identify and report risks with confidence that appropriate action would be taken. For example, during the assessment, a patient admitted for a day procedure was identified as having a communicable infection. Staff escalated the risk to managers, who promptly arranged for the patient to be accommodated in a single room on the ward to minimise the risk of cross-infection to others.

Staff understood the duty of candour. They were open and transparent and gave patients and families a full explanation when things went wrong. Staff received feedback from investigation of incidents, both internal and external to the service.

There was evidence that changes were made in response to feedback. Managers debriefed and supported staff following serious incidents. For example, when a patient deteriorated during a procedure and required transfer to NHS intensive care, staff raised concerns about the adequacy of the pre-operative assessment and the patient’s suitability for treatment at the service. Following this incident, the provider strengthened pre-operative assessment processes, introducing more robust criteria for patients with complex medical histories.

Staff did not consistently remain up to date with mandatory training, which posed a potential risk to the safe delivery of care and treatment and reduced assurance that patients were protected from avoidable harm. Compliance data showed completion rates of 88.2% for inpatient trained nurses, below the provider’s 90% target, and 80% for healthcare assistants. In theatres, compliance was higher at 96% for trained nurses and 90% for healthcare assistants, while the day unit reported 96% compliance for trained nurses.

Key safety-critical training areas were below the provider’s 90% target across surgical services. This included data governance, basic life support (adult and paediatric), immediate life support (adult and paediatric), and manual handling. Compliance was particularly low for practical basic life support, with only 40% of inpatient staff and 50% of theatre staff being up to date with training. Immediate life support training had been completed by 35% of theatre staff and 79% of inpatient staff. Manual handling compliance was also below target, at 57% for inpatient staff, 80% for day unit staff, and 70% for theatre staff.

These gaps reduced assurance that staff had the necessary skills to respond effectively in emergency situations and maintain patient safety. Although leaders had identified these issues and arranged additional training sessions, with staff booked onto resuscitation training, improvements were not yet embedded at the time of inspection.

The provider used a training system aligned to the Core Skills Training Framework (CSTF). CSTF is the UK benchmark for statutory and mandatory training, standardising learning outcomes, refresher intervals, and compliance across NHS and other healthcare organisations. Leaders reported that a system upgrade in late 2025 affected compliance reporting and training allocation, which contributed to reported reduced compliance rates. A full system fix was expected within 6–8 weeks following the assessment. In the interim, leaders manually tracked and calculated when training was due.

Medical staff completed and maintained their mandatory training through practising privileges arrangements. However, the provider could not provide assurance regarding compliance, as training completion rates for medical staff were not available.

We scored the service as 3. The evidence showed a good standard. 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 was a priority throughout people’s care pathway. Patients were assessed prior to surgery and findings taken into account when planning care and treatment. This may include cancelling or delaying the surgery in cases where an underlying condition was identified.

There was an admission criterion for both private and NHS patients. These criteria set out where they had limitations in services and therefore were minimised risks by excluding some patients. For example, people with high risk of needing additional support such as those requiring high dependency or intensive care post operatively. Patients requiring tests and investigations were given enough information to enable them to understand the procedure.

There were systems and processes to ensure the correct patients were treated throughout the patient journey. We walked the patient journey and tracked patient care from admission to the ward and day unit, to the operating theatre. We observed handover of patient information including all related identification checking processes, and found these to be in line with national safer surgery guidance. Once in theatre, the World Health Organisation (WHO) surgical safety check list was used to avoid harm. We observed completion of the process. Staff confirmed the surgical safety standards such as a stop the line policy was understood by them in the event of any concerns raised.

The transfer of patients from the operating theatre to the recovery was managed safely, with the anaesthetist retaining responsibility for determining the readiness for transfer. Suitably skilled and qualified staff accompanied patients in all areas.

Patient records were maintained using a combination of electronic and paper-based systems and were stored securely. The provider had recently introduced an electronic patient record system; however, some staff reported that they were still becoming familiar with the system and found it time-consuming to use.

Leaders advised that additional support had been provided during implementation, including backfilling clinical staff to enable training and system adoption. At the time of inspection, prescribing had not yet been incorporated into the electronic system and continued to be completed using paper records. Plans were in place to transition prescribing to an electronic system; however, no defined timeline had been established.

When overall responsibility for the care and treatment of a patient moved to a different service provider, such as transfer to the NHS, there was effective communication, which allowed for a seamless transfer.

The service had a transfer of care policy, supported by a logbook and checklist. We reviewed records and found these were completed appropriately when required, providing assurance that key clinical information was shared and risks were managed during patient transfers.

Care and support were planned and organised in partnership with patients, external providers, and community services to ensure continuity of care. For example, we saw effective partnership working for patients undergoing gender affirmation procedures, including strong collaboration with community services such as district nurses and general practitioners (GPs) and NHS care providers such as gender dysphoria clinics and mental health providers.

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

Staff understood how to protect patients from abuse, and the service worked effectively with external agencies to do so. Staff received appropriate safeguarding training for both adults and children.

Compliance data showed that 90% of eligible staff had completed safeguarding adults level 1, 96% had completed safeguarding adults level 2, and 100% had completed safeguarding adults level 3. For safeguarding children, 92% of eligible staff had completed level 2 training and 96% had completed level 3 training.

There were current safeguarding policies, and these reflected the national guidance for adults and children, including visitors. Staff knew how to make a safeguarding referral and who to inform if they had concerns. Expert safeguarding advice was available to support staff from Monday to Friday and staff knew how to contact them. There was a named nurse for adult and child safeguarding.

Safeguarding concerns were considered when an incident occurred and a referral or further advice sought, when necessary. There were links to external agencies and staff knew what happened when they raised concerns.

Staff knew how to identify adults and children at risk of, or suffering, significant harm and worked with other agencies to protect them. Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act.

Staff followed safe procedures for visitors visiting the wards and patients we spoke to told us they felt safe.

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

The service worked with patients to understand and manage risks. Treatment and care met patients' needs in a way which was safe and supportive and enabled them to do the things that mattered to them.

We spoke with 10 patients during the assessment who told us they felt listened to, that risks were clearly explained, and that they were involved in decisions about their care and treatment.

Patients undergoing gender affirmation procedures described a comprehensive approach, including access to information such as explanatory videos, and opportunities to speak with clinical nurse specialists, consultants, and the wellbeing team.

Patients across all specialities told us that their families and loved ones were encouraged to be involved in decisions about their care, where appropriate.

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

The design, maintenance and use of facilities, premises and equipment kept people safe. The design of the environment followed national guidance for healthcare buildings. Most areas were secure, with access controlled by swipe card to restrict entry and protect people using the service. However, the inpatient ward was accessible to members of the public. Leaders had identified this risk and recorded it on the service's risk register. While the portering and housekeeping base at the ward entrance provided an additional staff presence, there was no secure, controlled entry to the ward. This meant members of the public could access the ward without being observed.

Leaders advised that there were plans to introduce electronic access controls to this area, and CCTV was in place to support oversight. During the inspection, we observed staff challenging individuals on the ward to confirm they had a legitimate reason to be there.

The environment of the wards and other areas used for patient care reduced the risk of patient harm, and included, for example, safe flooring, handrails and window restrictors.

Fire safety equipment was available and had been serviced. Fire exits were clear and free from obstruction.

There was suitable equipment provided and used correctly, such as for patients who were at increased risk of pressure damage or a blood clot developing. Staff carried out daily safety checks of specialist equipment. There was ready access to both adult and paediatric resuscitation equipment on the ward, day unit, and in theatres.

Leaders maintained oversight of equipment to ensure it was safe and ready to use. Equipment audits were completed and outcomes shared with staff. Staff told us they had enough equipment to carry out their work safely and to support the treatment and care needs of patients. There were effective means of ensuring repair or replacement of broken or missing equipment.

Specialist equipment used in the operating theatres was used in accordance with national guidance and regulatory requirements.

Patients could reach call bells. Call bells were positioned by patient beds, and staff showed patients how to use them to summon help. We saw call bells were responded to swiftly and the noise level from unanswered call bells was minimal.

The service had suitable facilities to meet the needs of patients’ families when necessary. For example, we observed fold-out beds available on the inpatient ward to accommodate family members staying overnight.

Staff disposed of clinical waste safely, both inside and outside the building. Waste was segregated and labelled in accordance with the hospital policy. The risk of sharps injuries was minimised because of the safe management of sharp implements.

Hazardous substances were stored safely and information about products was available to staff. Patients reported that lighting was reduced at night, and the noise levels were minimised. Two patients, together with their family members, highlighted this helped them to sleep better and supported their recovery.

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

The service had enough clinical staff including nursing and support staff, with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. Staff were made aware of their shifts in advance and could make requests.

New staff received a full induction tailored to their role before they started work. Managers supported staff to develop through constructive recorded, annual appraisals and constructive clinical supervision of their work. Temporary bank and agency workers had a local induction to the area in which they were working.

Managers reviewed the number and grade of clinical staff, healthcare assistants and other key roles, needed for each shift in accordance with national guidance. Managers could adjust staffing levels daily according to the needs of patients. Theatre and recovery staffing was planned, based on activity and the skills needed for everyday and emergency work, including out of hours cover. We saw duty rotas for the last 3 months, which showed that all shifts had been filled. Some substantive staff had been taken from the clinical areas to support the introduction of the electronic patient record system. We saw that these shifts had been backfilled with regular bank and agency staff who were familiar with the service.

The service had low vacancy rates with inpatients having a 1.9% vacancy, day surgery 3.8% vacancy, and theatres 3.9% vacancy. The service had a low turnover rate of 3%, and low sickness rates of 4%.

Managers limited the use of bank and agency staff and, where used, requested staff familiar with the service. Patients undergoing gender affirmation surgery who required 1-to-1 care post-operatively were cared for by substantive staff who had received relevant training.

Staff spoken with said they felt the service was safe. They were able to take breaks during their shift.

Patients spoken with felt their needs were met in a timely way and we observed staff responded quickly to call bells. We saw patients were attended to in a kind and supportive way. Patients appeared comfortable and were engaged in conversations because there were sufficient staff.

The service supported the learning and development needs of staff and made sure staff received any specialist training for their role. Managers identified any training needs their staff had and gave them the time and opportunity to develop their skills and knowledge. For example, staff were able to undertake leadership courses, and specialist training for patients undergoing gender affirmation procedures.

Managers made sure staff attended team meetings or had access to the information shared, when they could not attend. We saw notes from team meetings and other general information was shared on notice boards an in electronic messaging services.

Managers supported staff to develop through constructive recorded, annual appraisals of their work and regular clinical supervision. If poor staff performance was identified, this was dealt with in a supportive way, with a view to improvement.

The service had enough allied health professional staff to keep patients safe and meet their needs. Patient pathways and their discharge was not delayed because of a lack of allied healthcare professional input.

There was oversight of medicines optimisation and ward-based support for staff from a pharmacist.

The service used resident medical officers (RMOs) to provide medical care to patients 24 hours a day, seven days a week. In independent hospitals, a resident medical officer (RMO) is a doctor who provides continuous on site medical cover, delivering first line assessment, routine and emergency care, supporting consultants, responding to deteriorating patients, and acting as the hospital’s immediate medical presence. At the time of the assessment the service had 2 RMO’s, who were knowledgeable about the surgeries undertaken by the service, and aware of the risks they needed to consider. They reported having positive working relationships with consultants, and the service had clear escalation processes that enabled them to raise any concerns promptly.

Consultant surgeons and anaesthetists were subject to a full assessment through the practice privilege process. They were required to provide evidence of appraisal and re-validation.

Surgical procedures and clinical decisions were carried out by doctors with appropriate seniority and speciality training. Patients were clear who the doctors involved in their treatment were.

The overnight and weekend provision was adequate, with access to the admitting consultant for advice or to attend, if necessary. The admitting consultant reviewed their patients regularly, including at weekends.

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 managed infection risks well. The service used systems to identify and prevent surgical site infections. Staff used equipment and control measures to protect patients, themselves, and others from infection. They kept equipment and the premises visibly clean.

Theatres and ward areas were visibly clean, free from clutter and had suitable furnishings which were clean and well-maintained.

The theatre environment followed national guidance, with separate areas to enable flow from clean storage, preparation through to an area for dirty equipment and waste management. There was storage for equipment including sterile packs, uniforms and linen. There was sufficient space for laying up theatre trolleys under a ventilation canopy, if required.

Surgical instrumentation was managed off site under a service level agreement, which involved the processing of items, delivery of these and collection after use for cleaning and sterilising.

There was a provider infection and prevention and control policy and supporting guidance that was accessible to staff. The providers guidelines reflected national Infection Prevention Control (IPC) guidance from Public Health England (PHE), and the Royal College of Surgeons. Staff had access to expertise in infection control as needed.

There was a programme of infection and prevention and control audits including for example, hand hygiene care, use of personal protective equipment (PPE), waste management, linen storage, patient equipment cleanliness, intravenous devices, catheter care, theatre environment including air flow testing, and water testing.

The service performed well in local IPC audits. In the most recent audits, the scores showed compliance with infection prevention and control measures in all clinical areas, with all audits achieving over 95% compliance.

Staff used records and data to identify how well the service prevented infections. The service monitored surgical site infection (SSI) rates, using Getting it right the first time (GIRFT) benchmarks. The service had an overall SSI rate of 0.45%, which was below the national average.

Staff cleaned equipment after patient contact and labelled equipment to show when it was last cleaned.

There were processes to enable staff to respond to infection prevention and control risks such as transmittable infections.

We saw staff were following infection control principles including compliant handwashing and the use of personal protective equipment (PPE) as outlined in the services PPE standard operating procedure.

Theatre practice minimised the risk of cross infection and we saw staff following best practise regarding the treatment and care of their patients.

The management of clean and used surgical equipment and the flow through theatre reduced the risk of cross contamination. Staff checked the condition of sterile packs before they were opened and prior to use.

There was appropriate testing of air exchange systems in theatres, and water outlets in both the theatres, day surgery unit and inpatient areas.

Staff understood the process for managing spillage of body fluids both on the wards and in theatres.

Staff supported infection prevention and control measures by following the uniform policy. Nail varnish and jewellery was not worn, and staff in clinical areas were bare below their elbows to allow for full hand decontamination.

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 happen.

The service used systems and processes to safely prescribe, administer, record and store medicines.

Staff followed systems and processes to prescribe and administer medicines. In theatres, medicines were not routinely drawn up in advance of operating lists. However, emergency medicines were pre-drawn and placed on a designated emergency tray, including atropine and propofol, which accompanied the patient from the anaesthetic room to theatre. Staff advised this was for emergency use only.

This practice was not in line with national guidance on the preparation of medicines. The concern was raised with staff during the inspection, and action was taken immediately. On the following day, no pre-drawn emergency medicines were observed.

Doctors reviewed each patient’s medicines on admission and provided advice to patients and carers about any changes. A pharmacist was involved in patient medicines reviews.

The service had clear guidance for staff about the safe use of antibiotics and opiates (Controlled drugs). The service had an up to date medicines management policy in place.

There were facilities for patients who wished to manage their own medicines. Patients who were able and wished to manage their own medicines were encouraged to do so.

Staff completed medicines records accurately and kept them up to date. There were accurate records of medicines administered in the operating theatre and recovery.

Medicines including intravenous fluids were stored in line with local and provider policy and reduced the risk of misuse and errors. Keys to the controlled drug cupboard were held by the nurses in charge of the ward and day surgery unit. In the operating theatres there were separate storage units for each room.

There was effective governance of medicines, for example, the service undertook medicines management audits including in-patient prescription and administration records, handling and storage of controlled drugs, medicines reconciliation, dispensing of oral liquid preparations, safe and secure handling of medicines, and patient’s own drugs-controlled drugs. All audit results achieved better than the provider’s 90% target.

Staff followed national practice to check patients had the correct medicines when they were admitted, discharged or they moved between services.

Staff learned from safety alerts and incidents to improve practice. Medicines incidents were reviewed, and actions were taken to reduce the risk of recurrence. For example, following a controlled drug error within the service, a thorough investigation identified contributing factors, including high levels of noise and distraction in the treatment room.

As a result, treatment rooms were designated as ‘quiet zones’ to minimise interruptions during medicines preparation and administration. Leaders told us that adherence to this change was being monitored, and treatment rooms were seen to be quiet zones during the assessment.

There was access to medicines needed in an emergency or at short notice at night and at the weekend through an internal pharmacy on call service.

There was sufficient equipment such as intravenous pumps, subcutaneous and self-administration pumps to allow the correct management of patients’ medicines.

Oxygen was prescribed, when used. Air outlets were capped to prevent it being administered instead of oxygen.