Practice Plus Group Hospital - Barlborough

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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

We looked for evidence that the service had a proactive learning culture and maintained safe systems of care. We looked for evidence that the service worked with people to manage risks and kept people safe from avoidable harm. We looked for evidence that the service was appropriately staffed and the environment was safe and clean.

At our last inspection we rated this key question as good. At this inspection the rating has remained good. This meant that the service had a maintained safe systems of care and had a proactive learning culture. The service kept patients safe from avoidable harm and worked with them to manage risks. The service environment was safe, clean and appropriately staffed.

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 service had a proactive and positive culture of safety, based on openness and complete honesty. They actively listened to concerns about safety and thoroughly investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Please refer to the surgery section in the report for this location for the main details about this quality statement.

Staff in the outpatients department understood what to report and were able to provide examples. They were able to explain how they reported concerns in line with the provider’s policy. Outpatients staff were able to provide examples of learning from incidents.

Outpatients staff were involved in hospital wide meetings where incidents and learning were discussed. Staff discussed learning in daily safety huddles, managers meetings and head of departments meetings.

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 patients moved between different services.

Please refer to the surgery section in the report for this location for the main details about this quality statement.

The outpatient referral and admission processes ensured that all essential information about the patient was received to determine if the patient’s needs could safely be met. We observed the pre-surgery consultation process as part of the inspection. The pre-surgery consultation was thorough, including medical history, risks, benefits, and procedural expectations.

The service provided all pre-operative checks in one visit to prevent patients having to return. Staff referred patients were for additional diagnostic scans if required at this stage. Patients also had a nursing and anaesthetic assessment, which included screening tests, blood tests and blood pressure monitoring.

The service had a did not attend (DNA) protocol. Patients would be followed up if they missed appointments. Patients had 3 opportunities to re-arrange before they were referred back to the GP. If a patient wasn’t suitable for surgery, they ensured the referring service was informed.

We scored the service as 3. The evidence showed a good standard. The service worked with patients and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff focused on improving patients’ lives while ensuring they were safe from bullying, harassment, abuse, discrimination, avoidable harm, and neglect. The service shared concerns quickly and appropriately.

Please refer to the surgery section in the report for this location for the main details about this quality statement.

Staff in the outpatients department described safeguarding processes and knew how to escalate and report concerns. They told us they would contact their line manager or the safeguarding lead for advice if it was needed. Staff gave examples of raising safeguarding concerns and spoke positively about the support from the safeguarding lead.

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 patients' needs that was safe, supportive and enabled people to do the things that mattered to them.

Outpatient staff communicated with patients so that they understood their care and treatment. They made sure people were involved in decisions about their treatment and understood any risks associated with their procedure. As the service did not have a high dependency area staff undertook an assessment to ensure that patients were not at high risk of complications.

Staff undertook assessments looking at risk and harm prevention, such as venous thromboembolism (VTE) assessments. Staff undertook MRSA screening of all patients.

For patients undergoing weight loss surgery, the service had a structured and multidisciplinary approach to risk management. Patients underwent a comprehensive assessment prior to surgery, including consideration of psychological risk. Consultants assessed patients’ medical history, eating behaviours, motivation and expectations of surgery.

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.

The outpatient area was well-maintained and fit for purpose. The department had a layout which supported the flow where patients saw consultants first, followed nurses and anaesthetists. Diagnostic tests were completed during the same visit, supporting efficient assessment without unnecessary movement delays. There was a separate outpatients area for ophthalmology with its own treatment room and small waiting area. Seating was suitable for patients with mobility needs, and the department was wheelchair accessible. There was adequate space in waiting in areas. Emergency exits clearly marked and unobstructed. Fire safety signage was visible. There was a resuscitation trolley within the department and staff documented routine checks. Sharps bins were not overfilled and were kept below their maximum capacity.

Fire safety arrangements were safe. Staff were able to describe the fire evacuation procedure and 98% of staff had completed fire safety training. Staff had completed Health, Safety and Environment training, with 99% compliance.

Staff had access to appropriate equipment to carry out treatments and consultations. Managers ensured electrical equipment had up-to-date electrical testing. Consumable equipment we checked was in date. Staff would raise concerns about safety or the premises or equipment, and were confident action would be taken in a timely manner.

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 patients’ individual needs.

Please refer to the surgery section in the report for this location for the main details about this quality statement.

The outpatient part of the service had enough clinical staff, including nursing, support staff, medical staff and allied health professionals, with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment. Staff within the department told us they felt it was staffed appropriately and they could always cover staff sickness and absence.

Hospital wide data indicated 97% of clinical staff and 98% non-clinical staff had completed mandatory training as of February 2026.

Staff told us they had supervision and appraisals which supported them to stay competent. Staff provided examples of accessing additional specialist training to support their roles, such as anaesthetist training.

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 department was clean, had the required easy clean furnishings and was well-maintained. Staff maintained equipment well and kept it clean. Cleaning records were up to date and demonstrated that areas were cleaned regularly. Staff adhered to infection control principles, including handwashing.

Staff and patients had access to hand gel, there were signs encouraging patients to use hand gel on arrival. Staff cleaned reusable equipment after it was used on patients. Staff cleaned beds after patients had used them. Staff had appropriate access to personal protective equipment (PPE).

Staff supported IPC measures by following the uniform policy. Nail varnish and jewellery were not worn, and staff were bare below the elbows.

Clinical and hazardous waste was managed safely. Waste was separated and labelled clearly so staff knew how to dispose of it correctly. A specialist company collected sharps and other hazardous waste. Sharps bins were not overfilled and were kept below their maximum capacity. During our visit to clinical areas, we saw staff dispose of waste safely, which reduced the risk of sharps injuries.

Staff had access to infection control expertise. The IPC Lead Nurse held regular meetings with IPC link nurses. These staff had protected hours for IPC related work.

The service had an up to date infection prevention and control policy and supporting guidance aligned with national standards, including those published by Public Health England and the Royal College of Surgeons.

There was a structured programme of infection prevention and control audits, and the service performed well.

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.

There were limited medicines within the outpatients area of the hospital. The medicines that were used were stored securely, and storage was monitored effectively. There were clear process for issuing outpatients prescriptions and prescriptions were clinically checked where required.

Staff had timely access to emergency medicines. Emergency medicines and portable oxygen were available within resuscitation trolleys, which staff checked daily.

Staff had access to policies and processes to safely manage medicines. The Medicines Management Policy set out responsibilities and, safe systems for prescribing, storing and monitoring medicines, which reflected current national guidance. The staff conducted regular audits of controlled drugs, non medical prescribing and VTE pathways. Staff completed inpatient medication chart documentation reviews quarterly and review of antibiotic use every six months. These activities helped promote safe practice and reduce the risk of errors.

Competent and trained staff administered medicines to patients. Staff completed documentation when they gave medicines accurately. Staff recognised any adverse reactions and responded quickly. Staff knew how to raise concerns in relation to medicine. Pharmacists were involved in medicines reviews seven days a week, including Sundays, with access to out of hours clinical advice when needed. Records in pre operative assessments showed staff documented each person’s medicines list before admission.