HCA Healthcare UK The Christie Private Care

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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.

At our last assessment we rated this key question outstanding. At this assessment it changed to good. This meant people were safe and protected from avoidable harm.

We assessed 8 quality statements.

The service had appropriate staffing levels and a suitable skill mix to deliver safe, high‑quality care, supported by extensive specialist input from NHS and private‑sector clinicians. The service worked closely with patients and partners to maintain safe systems and ensure continuity of care. Staff understood how to report incidents, felt confident to raise concerns, and described an open, no‑blame culture, although incident‑closure targets were not always met. The service helped people understand and manage risks holistically, ensured equipment and technology were well maintained, and consistently assessed and controlled infection risks. The service ensured medicines and treatments were safe and aligned with people’s needs and preferences.

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.

Staff we spoke with could tell us about the process for reporting incidents and felt confident to raise concerns. Many staff described the culture as being open with no blame. Staff told us they received feedback and learning following incidents and were able to share recent examples of this, including the actions taken in response.

Staff and leaders understood the duty of candour (DoC), which is the legal obligation for healthcare services and professionals to be open and honest with patients about any incidents that may have affected their care and treatment.

Systems were in place to ensure staff were made aware of incidents and any subsequent learning. Staff told us that ‘hot topics’ including incidents and complaints were discussed in daily huddles and described specific examples of learning from incidents. Pharmacy staff told us that they had introduced an additional weekly huddle to focus further on incidents and strengthen learning from near misses. We saw that staff boards displayed key updates and incident themes and trends to update staff.

The service had a proactive and positive culture of safety with a clear focus on learning from complaints, incidents, and patient feedback to improve the safety and quality of services. The service regularly reviewed and investigated incident data in line with good practice and Patient Safety Incident Response Framework (PSIRF) guidance. There were structured systems in place for reviewing incident trends through weekly Complaints, Litigation, Incidents and Patient Experience (CLIP) and Learning and Improvement Panels (LIP). The meetings were attended by clinical teams, managers, pharmacy and governance leads to review incidents, share learning, identify themes, and agree on actions. There was a focus on organisational factors, system-wide learning and evidence-based improvements.

We saw evidence of shared learning with staff through patient safety alerts. The alerts included details about incidents and what immediate learning and actions had been taken to reduce the risk of recurrence. The radiotherapy service also received memos from the partner NHS trust when there had been relevant incidents or concerns identified on site, which were communicated at regular team meetings.

The hospital provided incident data that included both medical, radiotherapy and outpatient services. Between November 2024 and October 2025, a total of 642 incidents were reported. The level of harm had been recorded as no harm for 82% of incidents and 8% low harm. The remaining 10% of incidents included expected deaths, near misses and 1 incident of moderate harm.

Leaders told us that there some delays in closing incidents due to the complexity of investigations and availability of staff to provide information about the incident. Incident data provided by the service showed that the hospital did not meet its target for closing incidents (68% compliance). Overdue incidents and their progress were monitored weekly through the CLIP meetings. We reviewed the meeting minutes dated 20 November 2025, which showed that progress had been made in reducing delays.

The service had reported no never events in the previous 12 months prior to our assessment. Never events are serious patient safety incidents that should not happen if healthcare providers follow national guidance on how to prevent them.

The service also had a structured process to review deaths that had occurred at the hospital. Mortality Review Committee (MRC) meetings were held weekly alongside CLIP meetings. We reviewed meetings minutes dated 20 November 2025, which showed that all mortality reviews had been completed within the target of 8 weeks.

The service had recently introduced a new ‘recall form’ process to review any patient transfers from the departments to the partner NHS critical care unit (CCU). It included key questions about the care provided, and events between the deterioration and the CCU transfer. This had highlighted areas of good practice and areas of improvement for the future.

We scored the service as 4. The evidence showed an exceptional standard. The service always worked with people 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.

The service had safe systems of care, in which safety is managed, monitored and assured. Safety and continuity of care was a high priority throughout patient’s care journey. There was a collaborative, joined-up approach to safety that involved patients, staff and other partners in their care.

All patients we spoke with were positive about safe care and continuity. For example, a patient who had used the service for over 3 years said they had always felt safe and never needed to explain their condition or treatment plan because staff were always informed and prepared for them on admission. Patient feedback data taken from surveys from November 2024 to November 2025 showed consistently excellent feedback. Radiotherapy (82 responses) and inpatient services (552 responses) reported an average of 99% ‘excellent’ or ‘very good’ ratings for safety‑related questions.

The service demonstrated a proactive approach to anticipating and managing risks to patients. Admissions were planned for in advance, and patients were assessed for any reasonable adjustments required.

Patient referrals to the hospital were made by consultants internally and externally or by their GP and could be admitted into the medical service as an emergency. There was a system in place for urgent review when clinically required and arranged by the senior nurse with the consultant and medical team. There were at least 2 beds that were available for emergency admissions and patients assessed as appropriate for transfer could be moved to different wards to accommodate emergencies. The service had resident medical officer (RMO) cover 24 hours a day, seven days a week.

Patients could use the partner NHS trust’s telephone hotline. The hotline service is a 24-hour telephone helpline service available to patients for advice and management on the side effects and complications of cancer treatments. We saw evidence of this in patient records. For example, a patient had contacted the hotline and was then referred by a clinical nurse specialist (CNS) for inpatient admission due to jaundice risk.

Staff used an electronic system to support effective communication between departments and with the partner NHS trust. Real-time alerts and messages could be prioritised according to urgency. Staff told us this improved response times and supported timely clinical decision-making. Alert cards were given to patients with port devices, or undergoing Systemic Anti‑Cancer Therapy (SACT), such as chemotherapy or immunotherapy to ensure they received immediate, appropriate care if they became unwell in the community.

The service ensured continuity of care, including when patients moved between different services. There were service level agreements (SLA’s) in place with the partner NHS trust so patients could access other services under NHS provision such as speech and language therapy (SALT), diagnostic imaging, critical care and complex discharge support. A radiology coordinator who was employed by the partner NHS trust could organise timely scanning using the trust’s imaging services, and systems were in place to ensure that in cases where a patient needed multiple different scans, these could typically be completed within the same day to avoid repeat journeys. Linked IT systems meant that pre-treatment scans taken by the partner NHS trust could be easily transferred and used by the service’s own linear accelerator.

The same electronic patient record (EPR) system was used across both sites which supported secure and up-to-date sharing across care partners. Referrals to the radiotherapy service were also sent using the same EPR system, which provided staff with the appropriate information to ensure the patient was safe for the planned treatment. At the conclusion of the course of radiotherapy, a treatment summary and any additional relevant details were included in the EPR so all clinicians could stay fully informed, which included information such as the total radiation dose received and any side-effects or complications.

The radiotherapy team ensured that the patient knew how to contact them if there were any urgent concerns between treatment visits and arranged a follow-up phone call after the conclusion of the course to check their wellbeing.

Staff worked collaboratively with each other to coordinate patient care and discharge needs. We saw evidence of this through our observation of twice-daily nursing handovers, daily ward rounds, and daily multidisciplinary team (MDT) ward meetings.

The haematology CNS team met weekly with the partner NHS trust to discuss all transplant patients, and information was shared at weekly haematology activity meetings, which included haematology clinical educators. Leaders told us that the process helped staff plan and review upcoming activity so that Systemic Anti‑Cancer Therapy (SACT) preparations were well organised and workforce planning met the demands of complex treatment regimens.

Staff used a triage RAG (red, amber, green) rating system to identify when a patient review was needed by a specialist CNS and/or consultant and ratings were shared at the daily MDT meetings.

The discharge coordinator role had recently been implemented to strengthen continuity of care and reduce delays in discharges. They worked with external partners such as social services to coordinate patients’ discharge needs. We saw evidence of this in patient records, such as liaising with the local authority for specialist equipment for a complex discharge. Discharge letters were sent to GP’s, and the patient also received a copy.

Staff used a system called ‘the golden patient’ to identify what patients were ready for early discharge the following day. This meant that staff, including the discharge co-ordinator and pharmacy could plan and prepare the discharge documents and medications required.

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 had safeguarding policies in place for adults and children to help staff recognise and report abuse and neglect. These were easily accessible electronically and we observed flowcharts from both policies in staff areas to help guide staff. The policies were in date, comprehensive and included roles and responsibilities. They had been updated and were in line with the most recent national guidance and best practice.

Staff knew how to identify adults and children at risk of, or suffering, significant harm and worked with other agencies to protect them. Staff knew how to make a safeguarding referral. The service had reported 15 safeguarding incidents in the previous 12 months prior to our assessment. The key themes were patients that required a deprivation of liberty safeguards (DoLS) application due to an assessed lack of capacity and patients expressing suicidal ideation.

Staff knew who the safeguarding lead was and how to contact them. The safeguarding lead at the service was the chief nursing officer.

There was a commitment to taking immediate action to keep patients safe from abuse and neglect. The safeguarding lead told us that safeguarding concerns were escalated and dealt with quickly and included working collaboratively with partners. For example, patients with suicidal ideation were referred to their in-house psychology service and staff liaised with GP’s and specialist services to inform them appropriately of this concern. There was a system in place to discreetly provide support for patients at risk of or experiencing domestic violence.

Safeguarding policies and the safeguarding training framework outlined the training requirements that staff needed to undertake in line with national guidance.

All staff received mandatory safeguarding training specific for their role. Data provided by the service showed excellent compliance with safeguarding training. Most staff groups had a compliance rate of 100% which exceeded the service target of 85%. For adult safeguarding training (levels 2 and 3) the average compliance across all staff groups was 99%. For children and young people’s safeguarding training (levels 1 and 2) the average compliance across all staff groups was 96%. The safeguarding lead had completed level 4 safeguarding adults training along with 2 other senior staff members.

Average compliance across all staff groups for Mental Capacity Act (MCA), DoLS and preventing radicalisation training was 100%.

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.

Patients told us they were informed about any risks and how to keep themselves safe. They were familiar with the 24 hour ‘hotline’ telephone helpline service that was available if they had concerns about their physical health.

Patient feedback data from surveys conducted between November 2024 and November 2025 showed very positive results in this area. For example, radiotherapy services (82 responses) and inpatient services (552 responses) each reported an average of 100% ‘excellent’ ratings for ensuring patients knew who to contact if they were worried about their condition after leaving hospital. In addition, 100% of responses were ‘excellent’ or ‘very good’ ratings for feeling involved in decisions about care and treatment.

The service had fully implemented ‘Martha’s Rule’ which is a patient safety initiative for escalating deterioration in patients. This process meant that patients, carers/family and staff could escalate concerns about a patient's deteriorating condition to a different, independent clinical team. We observed posters displayed in wards that clearly explained the process and included the relevant contact number.

The service had comprehensive policies in place to support staff with understanding and managing patient risks and deterioration. This included a resuscitation policy and a National Early Warning Score 2 (NEWS2) and Observation policy for the management of acutely unwell adults. The policies were owned by the partner NHS trust under a service level agreement. The NHS outreach team was available to review patients and provide support with resuscitation and escalation to critical care when required. Staff we spoke with were able to explain this process and gave examples of when they had accessed this support in a timely manner.

The service completed an audit of NEWS2 compliance, evidencing a consistent performance of 100% across the period November 2024 to November 2025. We observed good compliance with recording of NEWS2 in the patient records we looked at.

Sepsis management was carried out in line with the partner NHS trust’s clinical guidelines. Joint infection prevention and control (IPC) meetings were held monthly, during which sepsis pathways and related issues were reviewed.

The service had a system in place to audit sepsis recognition, escalation and treatment. Staff incident reported any potential sepsis breaches and in the previous 6 months prior to our assessment there had been no confirmed breaches identified.

Radiotherapy patients had pre-treatment appointments where the requirements of the treatment, including the number of visits and length of the course, could be explained to them. The team had procedures to accommodate more urgent referrals, where information could be given in advance by phone or letter before seeing the patient in person. The radiotherapy service also had systems to notify them of specific patient needs such as mobility or language requirements, infectious disease status, or implanted devices that might affect the treatment, and had procedures for managing these needs to ensure their radiotherapy could proceed in a timely way. The service also assessed patients’ mental wellbeing and could make adjustments to ensure the patient felt calm and supported

Staff took a proportionate approach to imposing restrictions on patients and told us they made an effort to avoid restrictive interventions. They described how they had de-escalated situations using person-centred approaches. For example, a patient who required 1:1 observation had become distressed and anxious due to staff presence in their room for extended periods. Staff responded by spending time with them in the café instead and arranged a room change to help reduce environmental triggers. Radiotherapy staff were also experienced in assessing a patient’s mental state prior to commencing radiotherapy and used strategies to help keep them calm and relaxed throughout the procedure so as not to jeopardise their treatment.

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.

Patients were cared for in safe environments that were designed to meet their needs. Inpatient rooms were spacious and had their own ensuite shower and bathroom facilities, with working call bells within arm’s reach. Accessible toilets were available in all departments and equipped with nurse call buzzers and emergency pull cords for patient safety. All patients we spoke with told us they had not experienced any issues with the equipment needed to support their care.

The overall environment and clinical areas were visibly clean and free from clutter. We saw that equipment, oxygen cylinders, and consumable items were stored appropriately. Stock rotation was good across the service, with minor gaps identified.

Responsibility for the radiotherapy equipment was safely transferred to a medical physics team each month for its routine service, and documented quality assurance and alignment checks were performed regularly on the radiotherapy equipment prior to its use on patients. The service used the co-located NHS trust’s medical physics team in the case that input from a medical physics expert (MPE) or radiation protection advisor (RPA) was required.

Equipment was visibly clean and in date for servicing. There was a service level agreement in place with the partner NHS trust for the management and maintenance of equipment. We reviewed the medical devices asset register, which demonstrated robust oversight of equipment and provided assurance that all devices in use were safe. Staff told us they had access to all the equipment they needed to do their jobs and repairs were completed in a timely way. Radiotherapy equipment had a rolling replacement plan in place, with an expected date.

All areas we visited were well maintained, with controlled access. The radiotherapy area had appropriate signage, security and mitigations to ensure accidental radiation exposures were avoided, which included both staff personal dosimeters and environmental radiation monitors. Local rules aligned with the partner NHS trust were present and accessible to radiotherapy staff, who had each signed appropriately to confirm they had read them.

Emergency equipment such as defibrillators, suction machines and oxygen had been serviced and were in date. The service had 3 resuscitation trolleys within their medical and outpatient areas and used a trolley owned by the partner NHS trust in the co-located radiotherapy department, which were secured with tamper-proof tags. Staff used an electronic system to record daily inventory checks of the trolleys, and the system prompted staff when checks were due. Audit data for these checks from May 2025 to October 2025 showed that the medical wards had an average of 2.5 missed checks per month. An associated action plan was in place, and improvement had been demonstrated. The radiotherapy service did their own independent checks that the emergency trolley they had access to was being regularly checked by the partner NHS trust.

All patients and relatives we spoke with explained they were very happy with the environment and how it met their needs.

The clinical waste and sharps disposal area was clearly identified and secured with a keypad. Sharps bins were dated correctly and were not overfilled. Bins to accommodate different types of waste were clearly identified, enabling safe disposal by staff. These included bins for cytotoxic waste and sufficient ‘spill kits’ were easily accessible in the event of cytotoxic spillage.

The linen room had separate areas for storing clean and dirty linen. Sluice areas were clean and well maintained with separate handwash sinks. Commodes and shower chairs were clean and looked new.

The service had a fire safety action plan in place following a fire safety assessment in January 2025. We observed that the risks identified had been actioned in a timely manner and the waste services action plan was aligned with the strategy.

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.

Patients we spoke with told us that there was enough staff on shifts to meet their needs and that they felt safe. Patient feedback data from surveys conducted between November 2024 and November 2025 showed that the radiotherapy service and inpatient services (634 responses) had 100% ‘excellent’ scores for ‘confidence in their consultant caring for them’.

Staff gave examples of how they planned patients’ admissions at the earliest opportunity for any new specialist procedures that had not been carried out before. The planning included providing bespoke training on the procedure for all staff involved in the patient’s care, as well as reviewing staffing levels for the planned admission. Staff reported that they source training independently if specific training was not available through the partner NHS trust. Staff said the preparation helped them feel confident in providing care and helped build trust with patients.

The service also worked with external partners to provide additional specialist staff to enhance the care and meet the needs of patients. The service had 2 additional clinical nurse specialists (CNS) and 3 consultants who were employed onsite by an external provider. The CNSs and consultants provided both onsite and remote support through a 24/7 rota. They provided support for complex patients including symptom management and end of life care.

Staffing levels

There were appropriate staffing levels and skill mix to make sure patients received safe, good quality care that met their needs.

The service used a workforce model known as ‘worked hours per unit of service’ and managers used this metric to adjust staffing to meet the needs of the patient. There were weekly meetings led by the head of clinical operations and daily huddles with the matron to review staffing. In addition, the role of the nurse in charge was to continually monitor staffing to ensure it was sufficient.

Each inpatient area had a defined ‘worked hours per unit of service’ target for nursing staff. Data provided by the service showed staffing levels of inpatient areas were close to their respective targets. Between May 2025 and October 2025, haematology achieved an average of 11 against 11.8 target and oncology an average of 8 against 8.5 target.

Other clinical teams were staffed on a fixed model with a set number of full-time equivalents (FTEs), based on a 40-hour working week. Data provided by the service showed that for the same time period, the target of 11 clinical nurse specialists and 10 resident doctors had been met. Other staff groups that met target was dieticians (2), psychology (2) and radiotherapy (7). Pharmacy staff had increased from 8 FTEs in May 2025 and had met the target of 11 FTEs by October 2025.

The medical service had 1 vacancy for a clinical nurse specialist, 2 pharmacy and 2 oncology vacancies. Some of these vacancies had candidates actively onboarding at the time of our assessment. There were no vacancies for resident doctors.

Within the medical service, most staff groups reported a 0% turnover for the previous six months. Data provided by the service showed average sickness rates between May 2025 and October 2025: Resident doctors (3.8%) physiotherapy and dieticians (0.6%) and oncology and haematology staff (4.6%). Sickness rates had reduced for most staff groups over this time period.

Data provided by the service showed that in the previous 6 months, 86.4% of nursing time had been delivered by permanent staff, 5.2% had been bank staff (already employed by the service) and 8.4% had been agency staff. Staff told us that agency staff usage for resident doctors had reduced from 20% in 2023 and was now 0% through 2025.

During our assessment we saw that actual staffing levels matched planned staffing on the wards we visited. Medical, nursing and radiotherapy staff we spoke with told us that they had enough staff to provide safe care.

There were 118 consultants who worked under practicing privileges across the hospital. Consultants working under practicing privileges were required to submit evidence of their clinical appraisal annually from the partner NHS trust. This was reviewed as part of the practicing privileges process. We reviewed the system for monitoring the practicing privileges requirements and found they were robust and demonstrated high levels of compliance including appraisals. Practicing privileges were also monitored by the Medical Advisory Committee (MAC). The MAC had representation from consultants of all specialities providing a multidisciplinary team approach.

Managers told us that shortages in staff could be immediately escalated to the executive on call via the department or duty manager 24 hours a day. Shortages in staffing that impact patient care or experience were reported as incidents. Leaders told us that within the medical service there had been no staffing incidents reported in the previous 6 months.

Training

Staff were experienced, qualified and had the right skills and knowledge to meet the needs of patients. Mandatory training was comprehensive and included infection control, sepsis, life support, learning disability and autism training. The service completed annual training needs analysis. Practice educators and managers monitored staff training and role specific competencies. A compliance report was provided every 2 weeks and shared with heads of department and senior team members.

Data provided by the service showed good compliance with mandatory training. All staff groups (nursing staff, medical staff, AHP’s, pharmacy and non-clinical) had exceeded the service target of 85%. Average compliance was 98% across all staff groups.

Resident doctors were required to complete advanced life support (ALS) and basic life support (BLS) training. Compliance was 88% (8 out of 9 doctors) and 100% respectively. Other staff groups including nursing staff, pharmacy and AHPs had an average compliance of 97% for BLS training.

The service had distinct competency frameworks in place for staff working in radiotherapy, oncology, and haematology. Each department head was responsible for monitoring and managing staff compliance with the support of the clinical practice educators. Clinical practice educators spoke positively about working closely with the partner NHS trust, which allowed staff to access NHS specialist training in addition to their in‑house training programme.

Oncology and haematology nursing staff competencies were comprehensive and included administration of blood products, IV infusion and Systemic Anti‑Cancer Therapy (SACT). Data showed that 8 of 10 modules had exceeded the service target and ranged from 90% to 100% compliance. Expired competencies were managed through a robust process that prevented staff from working in that area until they had been reassessed and successfully re‑validated.

Radiotherapy staff had achieved 100% compliance with all required competencies including treatment histories and initiating a radiation exposure.

There was a wide range of non-mandatory training sessions that included resuscitation simulations, ‘lunch and learns’, and specialist awareness days led by subject matter experts. Haematology staff could attend one to one teaching sessions with a haematology clinical nurse specialist and haematology clinical practice facilitators from the partner NHS trust who supported the department.

All staff we spoke with told us they had received an appraisal. Data provided by the service showed that 100% of all staff groups across the medical service had received an appraisal.

Some resident doctors told us there was limited opportunities for career progression due to the role not being a formal training role. They acknowledged that the post does not offer the same formalised training structure as NHS training programmes. This reflected themes from the latest staff survey, and leaders demonstrated strong responsiveness by putting a timely action plan in place to address them such as higher degree opportunities and quality improvement opportunities.

Other resident doctors told us they had good access to professional development despite the post not being a formal training role. They described having allocated study leave each year, which they could use flexibly to attend courses and conferences. Staff said training needs analyses were completed and that funding for development was readily available, and leaders encouraged them to apply. They discussed opportunities to pursue advanced qualifications such as the Executive Masters in Medical Leadership programme (EMML) which had been included on the department’s action plan.

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 robust processes in place for monitoring IPC that included service level agreements with the partner NHS trust. This included annual audits, monthly local audits and quarterly corporate audits. Staff had access to NHS training, shared learning and policies, including IPC, aseptic non-touch technique (ANTT), hand hygiene and waste management. The IPC link nurse also worked closely with the partner NHS trust’s IPC team.

All patients we spoke with were happy with the cleanliness of the wards and had no concerns regarding infection prevention and control (IPC). Patient surveys conducted from November 2024 to November 2025 demonstrated consistently high levels of satisfaction. Radiotherapy (82 responses) and inpatient services (552 responses) reported an average of 99% ‘excellent’ or ‘very good’ ratings for the cleanliness of the radiotherapy department, inpatient rooms and bathrooms.

Staff we spoke with were familiar with current IPC guidelines and completed IPC training as part of mandatory requirements with a service target of 85%. All staff groups including nursing, medical, pharmacy, AHPs and non-clinical staff had met the target with an overall average of 98%.

Audit data provided by the service showed high compliance with IPC against a 85% target. Environmental audits completed between October 2024 and September 2025 reported average scores of 98% in radiotherapy, 96% in oncology, and 95% in the haematology transplant unit.

Hand hygiene audits for the same time period, showed consistently high compliance with reported average scores of 100% in radiotherapy, 100% in oncology, and 100% in the haematology transplant unit.

The annual IPC audit report (March 2025), covering oncology, radiotherapy and haematology, showed compliance rates between 93% and 99%, exceeding the 85% target.

The service monitored infections, including those acquired in hospital or the community. Data provided by the service showed that between November 2024 and October 2025 there was a low number (2) of hospital‑acquired infections. There had been no outbreaks of infections in any ward or department in the previous 12 months.

The service investigated hospital‑acquired infections and took prompt action to strengthen infection‑control measures and prevent further cases. For example, following a cluster of Carbapenemase Producing Enterobacterales (CPE) incidents on the haematology unit, staff implemented strengthened infection‑control measures. Although investigations did not identify clear causative factors, the team increased screening frequency, delivered additional training and enhanced environmental cleaning. These combined actions led to a marked reduction in CPE cases.

Staff did not have concerns regarding IPC practices and procedures and were aware of their roles and responsibilities around IPC. We observed that wards, inpatient rooms and the general environment were visibly clean and tidy.

The service had processes in place that demonstrated clearly what areas and items was the responsibility of housekeeping, catering or clinical teams. This included cleaning checklists and a cleaning scope of works that was in line with the most recent national cleaning standards. Cleaning task schedules were detailed and outlined all areas (clinical and non-clinical) with daily task allocation sheets. Housekeeping staff we spoke with demonstrated a good understanding of the cleaning process and were aware of what areas required deep cleaning based on patients’ infection status and immune vulnerability.

The housekeeping manager completed weekly reviews of cleaning checklists. Data provided by the service showed that in October 2025, 270 checklists for the medical division and outpatients were audited. The results showed 96% compliance (and managers told us that any gaps were addressed in a timely manner by housekeeping assistants.

There were appropriate systems in place for the storage and disposal of clinical waste, including sharps and cytotoxic waste. Waste was labelled and dated.

There was sufficient personal protective equipment (PPE), sinks and hand sanitiser at entryways and around clinical spaces. Staff followed hand hygiene and bare below the elbow protocols when attending to patients. Hand towels and soap dispensers were adequately stocked.

Patients who had infections were barrier nursed; signage was placed on the patient’s door to inform staff and visitors. Staff used appropriate protective clothing when caring for patients to prevent the risk of infection.

The service had adopted a clinical waste strategy that was focused on national sustainability objectives and being environmentally responsible. Managers told us that this had led to improved waste management and a reduction in overall waste volumes.

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.

Medicines, including controlled drugs, were stored securely across all areas we inspected. Medicines were stored in electronic medication cabinets and were replenished by pharmacy technicians. The cabinets were secure and required two staff thumbprints to access medicines. The system also recorded all staff access.

Controlled drugs were stored in separate cupboards with key‑code access, and we saw that controlled drug registers were correctly completed with two staff signatures as required. We reviewed a sample of medicines, and they were all within their expiry dates.

Cytotoxic drugs were not stored on the ward; they were requested and dispensed by pharmacy on the day the drugs were required.

Stock reconciliation for controlled drug registers and electronic medication cabinets were undertaken twice a day. This was supported by weekly full stock checks. We reviewed records that showed fridge and room temperatures had been checked daily.

The service had robust systems in place to ensure medicines were appropriately prescribed, supplied and administered in line national guidance. For example, pharmacists reviewed each inpatient daily and completed medicines management checks, prescription reviews and weekly antimicrobial stewardship ward rounds.

Staff managed medicines effectively, including controlled drugs and the service routinely monitored compliance. For example, the service ensured chemotherapy was prescribed only by suitably competent staff and that medicines had been approved by the governance committee. Certain radiotherapy staff were designated non-medical prescribers and had authorisation to do so from both their own providers non-medical prescribing group and the partner NHS trust, using the electronic prescribing service. This was specifically for the provision of light sedation for highly anxious patients attending radiotherapy treatments.

Staff used an electronic chemotherapy prescribing system and there were robust systems in place to check chemotherapy drugs before they were administered. Chemotherapy drugs were only released by pharmacy and patient bloods were checked to ensure bloods were within the right parameters of accepting the chemotherapy. Pharmacists reviewed patients daily and medicines were adjusted according to the daily medical review. We saw evidence of this in the patient records we reviewed.

The service provided data from controlled drugs audits. From January 2025 to July 2025, pharmacy had achieved 86% compliance, inpatients (oncology) 88% and haematology 88%. Audit data for inpatient safe and secure medicines storage demonstrated an average compliance of 98% over the same timeframe.

The service carried out quarterly audits of the assessment and management of neutropenic sepsis with an associated action plan for any areas of improvement. Data provided by the service showed that average compliance was 99.5% between December 2024 and September 2025.

Staff followed the corporate medicines management policy and antimicrobial stewardship policy. They were comprehensive and had been updated to reflect national guidelines including United Kingdom Health Security Authority (UKHSA).

Governance and monitoring were supported by a bi‑monthly Pharmacy Antimicrobial Stewardship (PAS) group.

We looked at data provided by the service for antimicrobial stewardship treatment audits from July 2024 to December 2024 and July 2025 to December 2025. Audit data included 16 metrics and for those applicable all scored 95% and above. The majority of metrics were 100% compliant, such as the recording of allergy status, patients having a clear documented plan and antimicrobials being reviewed within 72 hours of initiation. There was an associated action plan for any areas of improvement and all actions were complete or on track.

In September 2025, the service transitioned to a new electronic prescribing and medicines administration system. This was designed to streamline the medication management process and replaced the paper-based system used previously. This meant staff could prescribe and manage medications electronically. The new system aimed to reduce medication errors and enhance patient safety. Staff spoke positively about the new system and felt it was better than using paper records. There had been one audit undertaken for medicines reconciliation since the launch of the new system, which showed 100% compliance.

The service had a pharmacy manager who was supported by 3 lead pharmacists across oncology, haematology and surgery. The pharmacy team had 3 pharmacists and 3 pharmacy technicians including a lead and senior role. The team provided on-call support out of hours, 7 days a week. There were policies in place that covered out of hours provision for pharmacy that gave clear guidance to staff.

Staff told us that there was a strong focus on discharge medications and MDT working to ensure medicines were dispensed timely to support discharges. They said that the responsiveness of the pharmacy team had improved and this had been reflected by more positive feedback from nurses and a reduction in complaints about delayed medicines.

The pharmacy service operated in line with the partner NHS trust’s governance arrangements, alongside the provider’s own corporate processes. The pharmacy team had weekly team meetings to review incidents supported by monthly meetings to discuss risks and performance. There was pharmacy representation at the weekly hospital-wide incident meetings and corporate governance meetings.

Consultants proposing the use of a medicine not listed on the NHS formulary completed an evidence‑based request form, which was reviewed and approved by the protocol team and clinical lead. The service also had a process and policy in place for using new drugs that had not been used before.

Staff reported medication related incidents. Over the previous 12 months, there had been 103 medication related incidents reported between both the medical service and outpatients. All incidents were rated as no harm and actions had been taken with lessons learnt shared with staff.