Practice Plus Group Hospital - Barlborough

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 clear priority for everyone and that leaders had embedded a culture of openness, learning and collaboration. The service had effective systems for recognising and responding to deteriorating patients across wards, operating theatres and recovery areas. Patients received care that consistently reduced the risk of avoidable harm, including venous thromboembolism and infection. Staff carried out safety checks before procedures and worked well together to make sure the right people received the correct care. Medicines were managed safely, safeguarding arrangements were effective, and staff obtained informed consent before procedures. Staff completed mental capacity assessments for patients who presented as not having capacity to consent to care and treatment, and made decisions in people’s best interests.

At our last inspection, we rated surgery as requires improvement for this key question. At this inspection, the rating improved to good because leadership oversight, safety systems and staff practice were effective and well embedded, and people were protected from avoidable harm throughout their care pathway.

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. Managers actively listened to concerns about safety and thoroughly investigated and reported safety events. Lessons were always learnt to continually identify and embed good practice.

The service managed patient safety incidents well. Staff said they understood what to report and described examples such as medication errors and falls. They were able to explain how they reported concerns in line with the provider’s policy. Staff recognised and reported incidents and near misses. Staff reported incidents, including near misses and day‑of‑surgery cancellations, which showed a positive reporting culture and a focus on learning and improving safety.

The service used electronic system for reporting incidents and 98% of staff had completed training on how to use this. Leaders told us they also offered drop‑in sessions for staff who wanted extra support to use the system.

Managers investigated incidents and shared learning with staff. We reviewed three recent investigations and found leaders took proportionate action to reduce the risk of recurrence. Staff said they received feedback following investigations, and managers provided debriefing and support after serious incidents. Staff discussed learning in daily safety huddles and managers’ meetings. Leaders also shared learning during clinical governance meetings, and at quarterly senior clinical away days. Learning points were also circulated to other service locations through flash alerts.

The service had a current patient safety incident response policy that reflected national guidance. The policy explained how leaders should prioritise responses and how to identify learning and improvement actions.

The service monitored and analysed incidents to identify trends and themes. We saw evidence that leaders had carried out an annual incident review, from 1 January 2025 to 1 January 2026. This examined all reported incidents, including surgical site infections, venous thromboembolism events, patient deaths and never-event. A never event is a serious and preventable mistake in healthcare that should not happen if the correct safety procedures are followed. There had been one never-event in the year before our assessment. The incident involved a small piece of wire that was unintentionally left inside the person after a procedure. Learning from the investigation led to practice changes, including the introduction of routine X‑rays if there was any uncertainty about the removal of any items during the procedure. Leaders commissioned thematic reviews when needed, such as for venous thromboembolism and patient deaths, and sought external review from senior clinical specialists at other sites. This helped them to identify themes and risks, learn from incidents, and take action to improve safety and reduce the risk of similar events happening again.

The service provided mandatory training in key safety areas, and managers monitored compliance closely. Mandatory training completion was 97.93% on 23 February 2026. Managers reminded staff when training was due and ensured compliance remained high to support safe practice and effective incident response.

We scored the service as 3. The evidence showed a good standard. The service always worked with patients and healthcare partners to design, establish and maintain safe systems of care, in which safety was always well managed and monitored. They made sure there was always continuity of care, including when people moved between different services. Staff ensured they passed on relevant information whenever responsibility for care moved between clinical areas or external providers.

Safety and continuity of care was a priority throughout patient’s care pathway. Patients were assessed before surgery, and staff used the findings to plan care and treatment. There was an admission criterion for both private and NHS patients. These criteria described the service’s limitations and reduced risks by excluding patients who required higher levels of support. High‑risk cases were reviewed in a multidisciplinary team meeting, and the medical director provided a second opinion before acceptance.

The service used systems and processes to ensure patients received the correct treatment. Staff followed identification checks from the ward through to the operating theatre. We observed handover processes which demonstrated continuity of care. Staff in theatres used the World Health Organisation (WHO) surgical safety checklist, and we saw it was completed in full. Staff also understood the stop‑the‑line policy and described how they would raise concerns during the procedure.

The transfer of patients from the operating theatre to the recovery area was managed safely. The anaesthetist determined if a patient was ready for transfer and handed over care to the recovery nurse. People were accompanied by suitably qualified staff in all areas.

Patient records were a mixture of electronic and paper‑based and were kept securely. Staff stored paper records in locked trolleys. Electronic systems were accessible and reliable, allowing completion of records at the point of care.

When a patient needed to move to another provider, such as the NHS, staff communicated effectively to support a safe and seamless handover. A consultant‑to‑consultant referral took place before a transfer, and nursing staff completed a Situation, Background, Assessment and Recommendation (SBAR) handover form to ensure paramedics and receiving teams had clear and sufficient information.

Patients’ care and support was planned with them and in partnership with other agencies to ensure continuity throughout the pathway. The rehabilitation and discharge coordinator completed pre‑operative assessments and contacted patients before admission to identify any support or equipment needed at home after surgery, including referrals to social care. They also worked closely with clinical teams and physiotherapists to ensure assessments were timely and that plans were communicated clearly across disciplines. Staff worked with local authorities when required, which helped to ensure safe and co-ordinated discharge planning. They also provided patients with information about other community resources that could support them once they returned home.

Staff worked with local authorities when required, which helped to ensure safe and well‑coordinated discharge planning, and they also provided patients with information about other community resources that could support them once they returned home.

Partner and stakeholder organisations reported confidence in the service. They described the service as safe, effective and aligned with national standards. They stated the service had strong governance, clear escalation processes and effective multidisciplinary working. They reported positive patient experiences. Stakeholders confirmed they were satisfied that systems, processes and the quality of care delivered under contractual arrangements were safe and effective. Stakeholders also confirmed the service worked well with other clinical providers through joint governance meetings.

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 concentrated on improving patient’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 up to date safeguarding policies, and these reflected national guidance for adults, children and visitors. These were aligned with the Care Act, Working Together to Safeguard Children and the intercollegiate frameworks. They set out clear processes for referral, information sharing and working with statutory partners.

Patients were protected from the risk of abuse because the service worked with them and healthcare partners to understand how best to keep them safe. Staff focused on protecting patient’s rights to live free from abuse, neglect, harassment, discrimination and avoidable harm. Patients told us they felt safe.

Staff understood their safeguarding responsibilities and completed safeguarding training for adults and children. Data from February 2026 showed that 88% of staff had completed safeguarding training for Adult Safeguarding Level 3 and 96% for Safeguarding Children Level 3. Leaders told us due to a limited availability of online slots for the virtual element of the course, fewer staff had completed the adult safeguarding training. The safeguarding lead had arranged additional face‑to‑face training sessions to improve compliance.

Staff confidently described safeguarding processes and knew how to escalate concerns. They said they contacted their line manager or the safeguarding lead for advice and felt supported in doing so. Staff gave examples of raising concerns and completing follow up actions. .

The service had raised 18 safeguarding concerns in the past 12 months. Most were reviewed and resolved without meeting the threshold for referral. Two safeguarding referrals were made, including one joint referral with a partner organisation. Both cases were investigated, closed and followed up by the safeguarding lead.

The safeguarding lead was on site two days a week and contactable at any time. They were supported by a safeguarding champion in the outpatient department. The safeguarding lead liaised and received supervision from the local authority. They attended annual safeguarding forums and maintained links with external agencies to ensure concerns were shared promptly.

We scored the service as 3. The evidence showed a good standard. The service worked well with people to fully understand and manage risks by thinking holistically. They provided care that met patient’s needs and was safe, supportive and enabled people to do the things that mattered to them.

The service worked with patients to understand and manage risks by taking a holistic approach. Staff provided care that was safe, supportive and aligned with what mattered to people. They made sure people were involved in decisions about their treatment and understood any risks associated with their procedure.

One patient told us they were reassured when staff identified concerns about their increased blood pressure. Staff documented assessments clearly, and we saw records confirming that the risks of procedures had been explained to patients.

Staff used nationally recognised tools to assess and monitor risks. The Malnutrition Universal Screening Tool (MUST) was used as part of routine risk assessments to identify patients at risk of malnutrition and to inform care planning. Staff also used the National Early Warning Score 2 (NEWS2) to monitor vital signs and escalate concerns about deteriorating patients. Venous thromboembolism (VTE) assessments and appropriate prophylaxis were completed in line with best practice. In theatres, staff completed the World Health Organization (WHO) Surgical Safety Checklist to support safe surgical processes.

For patients undergoing weight loss surgery, the service had a structured and multidisciplinary approach to risk management. The service did not classify these procedures as cosmetic. Leaders said surgery was offered only to patients with longstanding unsuccessful weight management affecting health.

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. Dietitians were involved in providing ongoing support, and patients with a history of disordered eating were identified and followed up appropriately. Where required, additional psychological assessment tools were used.

All weight loss surgery patients were reviewed by an MDT to ensure risks were assessed and managed. This approach supported safe decision-making and helped ensure patients were appropriately selected and prepared for 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 and facilities supported the delivery of safe care.

The environment of the wards and clinical areas reduced the risk of patient harm. Flooring complied with national standards for clinical areas.

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 could access and use appropriate equipment correctly. Consumable products were all clean and in date. Theatre equipment met national guidance requirements. Staff carried out regular safety checks of specialist equipment. A resuscitation trolley was located close to the area of highest risk, and staff documented routine checks.

Leaders maintained oversight of equipment through quarterly Health, Safety and Environment audits. The most recent audit in January 2026 showed 100% compliance. There was a clear asset management process which ensured equipment was serviced, replaced or upgraded when needed.

We noted some storage issues in theatre, including stock stored in corridors and areas of clutter. Although fire safety arrangements within the service were generally good, we identified that the storage of items in these areas could increase the risk of obstruction in the event of an emergency and required review. Leaders informed us there had previously been a plan to expand the storage space, but this was halted due to financial constraints. Leaders also told us this issue was recorded on the risk register. This concern had been identified during the previous inspection.

We noted some storage issues in theatre, including stock stored in corridors and areas of clutter. This concern had also been identified at the previous inspection. Leaders told us actions had been taken since the last inspection. This included converting a consulting room into additional storage space. However, increased activity had led to further storage pressures. Leaders said the risk was monitored, recorded on the risk register. Leaders told us they managed this risk without compromising patient care. They ensured theatre corridors remained clear, allowing beds to move safely between areas. The service also ensured emergency equipment were always accessible. These arrangements were monitored regularly. Staff also carried out frequent emergency scenarios and fire drills to test the safety and accessibility of the environment.

We scored the service as 3. 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. This included nursing, support, and medical staff. It also included allied health professionals. Staff told us they felt the service was safely staffed and were able to take their breaks. Staff had the right qualifications. They had the necessary skills, training and experience to keep patients safe. In addition to clinical teams, the service also had non‑clinical staff who supported the smooth running of the service. Data indicated 97% of clinical staff and 98% non‑clinical staff had completed mandatory training as of February 2026.

Patients told us their needs were met in a timely way, and we observed staff responding quickly to call bells.

The service had a recruitment process which ensured staff were recruited safely New starters received a role‑specific induction and were supported to complete mandatory training, with access to senior colleagues throughout.

The service supported staff to meet their learning and development needs and ensured they received specialist training relevant to their roles. Staff completed mandatory training including Immediate Life Support (ILS) for nursing staff, with 97% compliance, and Advanced Life Support (ALS) for consultants, with 94% compliance. ILS provides specialist early‑resuscitation training to support rapid assessment and safe defibrillation of a deteriorating patient. ALS provides specialist advanced training to equip clinicians to manage airways, interpret complex rhythms, administer resuscitation drugs and lead cardiac arrest responses.

The service had formal arrangements for a resident medical officer (RMO) to be on site when patients were receiving care and treatment. This meant a qualified doctor was always available, including overnight. Medical support was immediately accessible if a patient became unwell or needed an urgent review. We saw a record of the RMO being called to review a patient during the night.

Surgical procedures and clinical decisions were carried out by doctors with appropriate seniority and specialist training. Consultants had pre-operative consultations with patients before surgery, and we observed a ward round led by the lead consultant anaesthetist.

We scored the service as 3. 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 risks well and had effective systems to monitor and prevent surgical site infections (SSIs). The service commissioned thematic reviews they noticed an increase of SSIs. UK Health Security Agency (UKHSA) data for 2024/25 showed very low SSI rates: 0.1% for hip and knee replacements, rising to 0.2% for hip replacements when including readmissions. This meant patients using this service had low risk of getting an SSI in this date range.

The clinical areas were designed to support good infection control. Floors and surfaces were easy to clean, and the skirting boards were curved to remove hard‑to‑reach corners. This meant staff could keep the area hygienic and meeting national healthcare building standards. Water systems were well maintained, and regular checks were carried out to keep people safe from water borne infections.

Staff kept clinical areas clean and well maintained. The theatres had separate clean and dirty areas to keep items apart to stop germs spreading. Theatre practice minimised cross‑infection risks. The flow of clean and used instruments reduced the risk of contamination. Managers ensured reusable surgical equipment was decontaminated in line with best practice

Staff used equipment and control measures to protect patients from infection. We observed staff using appropriate personal protective equipment, including aseptic non‑touch technique (ANTT) when providing wound care. We also observed good hand hygiene by staff between patient contact.

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. Recent audit results showed 96% compliance in both ward and theatre/minor operations audits, which were completed monthly. The service also took part in Patient‑Led Assessments of the Care Environment (PLACE), scoring 99.07% for cleanliness and 100% for condition, appearance and maintenance in 2025.

Staff understood how to respond to infection‑related risks. No patients required isolation during our visit, but staff described isolating patients immediately if they suspected infection, such as any new diarrhoea, and would take samples promptly.

Staff supported IPC measures by following the uniform policy. Nail varnish and jewellery were not worn, and staff were bare below the elbows. Hand sanitiser dispensers were available for patients and staff, and handwashing facilities were located appropriately in each clinical area.

We scored the service as 3. 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.

Patients received their medicines safely because staff followed clear steps for every task. They prescribed, gave, recorded, and stored medicines consistently in all areas.

Staff prescribed and administered medicines safely. Doctors reviewed each patients’ medicines on admission and gave advice about any changes. 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.

Pharmacy staff helped make medicines checks safer. They reviewed new patients’ medicines, including those brought from home. Pharmacists attended ward round to review in-patient prescribing and for discharge. Discharge medicines were dispensed by the in-house pharmacy when require or TTO (To Take Out) pack were utilised when the pharmacy was closed. TTO packs are pre-labelled with common direction to aid discharge.

Staff kept accurate and complete medicines records. Staff explained that people taking critical medicines, such as insulin or medicines for Parkinson’s disease, were highlighted during nursing handovers. Critical medicines are locally determined, and in some scenarios, delay or omission of treatment can lead to severe harm or deterioration.

Sufficient medicines including controlled drugs (CD) were stored securely and records indicated they were stored within their recommended temperature ranges. Additional CD records were held and balances checked by staff twice a day and when administering medicines These arrangements were followed consistently in theatres and ward areas.

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.