Kinvara Private 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 rated Safe as Good. The environment was clean and equipment was well maintained and was safe for use and that staff were trained to use equipment.

Medicines and medical gases were managed and stored correctly.

Staff had received safeguarding training and staff we spoke to knew how to raise concerns and those we spoke to knew who the freedom to speak up guardian was.

Staff described a culture where they could raise concerns, and they learnt lessons from incidents.

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.

Patients told us they felt safe and did not have any concerns.

Staff identified, reported and managed incidents in line with the provider’s incident reporting policy. Staff told us they were encouraged to raise concerns and could easily access the electronic incident reporting system. Staff we spoke with could describe recent incidents and told us they attend post incident debriefs. These were held as soon as possible following the incident and was attended by a multi disciplinary team for a broader scope of input. It enabled them to reflect on the incident as a team and identify learning points without blame.

Managers shared incidents with staff at team meetings. We reviewed theatre and ward team meeting minutes, which showed incidents had been recorded and discussed. The minutes documented how lessons learnt had resulted in improvements being made. Currently units of blood were sourced from the local trust. The service told us they were planning to provide a blood stock on site for emergency use in response to an incident as from the beginning of November. We saw they had installed a new dedicated blood fridge, this was alarmed if it went outside of temperature range and escalated to the RM if out of hours. The fridge would hold 2 units of blood, any further blood required would be obtained locally.

There had been 1 never event reported at the hospital in the previous 12 months. A never event is a serious, wholly preventable patient safety incident that should not occur if the available preventative measures have been implemented by healthcare providers. The service undertook a full review and took appropriate action to prevent a reoccurrence.

Senior leaders told us that they had a positive reporting culture, which was corroborated by staff that we spoke with during the assessment. They were focused on supporting staff to maintain the quality and detail used when recording incidents on the reporting system. Incidents were investigated by senior staff with the appropriate level of training. Incident records were completed appropriately, and remedial actions were put in place to aid learning and improvement. Lessons learned from safety incidents resulted in changes that improved care for others.

We heard one example of a patient who deteriorated post operatively. The service provided additional and enhanced training and strengthened their escalation policy to align with other providers. They also provided post operative information flash cards to staff to refer to, formalised the handover process and ensured all staff had completed an effective communications course.

Staff we spoke with on the wards demonstrated understanding of the duty of candour, senior staff and leaders had a good understanding and we saw this was carried out appropriately. The duty of candour is a regulatory duty that relates to openness and transparency with patients if their treatment causes or has the potential to cause harm or distress. The service had a duty of candour policy and staff followed this process for any incidents rated moderate harm and above.

The service sent all incident investigations for external review and took immediate actions to remove any ongoing risks to patients. Following an incident, the service leads held debriefs and talked through the investigation findings with all staff once completed to ensure all staff were informed of any learning and involved in any ideas for change.

Patients told us that they had confidently chosen the hospital and consented to the referral by their GP. They reported a collaborative approach and good communication between the hospital and their GP. They told us they had a pre-operative assessment to determine their needs and preferences.

The service had exclusion criteria that identified people with complex needs who could not be admitted for treatment. The hospital had relevant policies and service level agreements in place. This included an agreement with the nearest NHS hospitals for emergency blood supplies and the transfer of deteriorating patients. A handover of nursing and medical records was completed when a person was transferred to another service or discharged.

Staff understood how to manage people’s risks during an emergency. They told us they carried out routine observations during treatment and people whose health deteriorated were escalated for medical input and promptly transferred to hospital if they required emergency treatment.

The service had several daily MDT (multidisciplinary team) safety huddles that included the head of clinical services. We saw that the team discussed serious incidents, equipment issues, patient risk, safeguarding, discharges and staffing levels.

Many staff we spoke with described the process they followed if they observed a patient safety risk. They explained they worked to the principle whereby all members of the care team were empowered to raise a concern about a patient’s safety or treatment at any time and this would be reviewed.

We collected feedback from external partner services that worked collaboratively with the service. Partner feedback was very positive about safety and continuity of care. They said regular meetings had enhanced the management and oversight of patients and minimised waiting times for appointments. They told us that they had strong links with the managers and that staff were dedicated, proactive and committed to patient care.

We saw the system for transferring patients was very efficient. The service had significantly supported the local trust’s elective activity and increased their capacity. At the time of our assessment, 98% of surgery for hips and knees was provided for NHS patients.

The views of patients were listened to and considered through participation groups or surveys. The service used the results to make changes and improvements to patient care and safety.

Patients told us they had not experienced any instances of abuse or neglect at the service.

The service provided training in line with best practice. Although the hospital did not provide services for children and young people, staff were required to complete level 2 child safeguarding training and advanced. Records for the current training year showed that all theatre and ward staff had completed levels 1, 2, and 3 adults and children and adults safeguarding training. Data showed that all safeguarding training compliance was 100% across all staff groups.

The head of clinical services was the safeguarding lead. They had completed the higher level of safeguarding training for children and adults, as did the medical director. Staff understood how to make a safeguarding referral and who to inform if they had concerns. They knew how to access support from the local safeguarding team. The provider’s safeguarding policy instructed staff on how to identify and report any safeguarding concerns, including making referrals internally and to external agencies, such as the local authority safeguarding team. The staff we spoke with were aware of the provider’s safeguarding policy.

Staff told us that learning from any reported safeguarding incidents was shared as part of daily huddles and during routine staff meetings. Staff had safeguarding supervision with managers to discuss specific cases and to reflect on the actions and outcomes.

The service had a safeguarding sub-committee and shared reports at the monthly patient governance committee meetings.

Patients told us staff explained any risks associated with their treatment and kept them up to date about any changes to their care and treatment. They told us they received post operation phone calls within 24 hours of being discharged and had support if they needed it.

Staff understood how to identify and manage risks. They told us they regularly reviewed risk assessments and discussed any changes with patients and their relatives or carers. Staff told us new or emerging safety risks were discussed during daily safety huddles.

Staff knew how to identify and manage patients with suspected sepsis or those whose health deteriorated. Staff used the recognised national early warning score systems (NEWS2) to identify deteriorating patients. They told us that they would escalate deteriorating patients, and conditions such as venous thromboembolism (VTE – blood clots), to the resident medical officer (RMO). The RMO was available 24 hours a day and worked 24 hours at one time for continuity. They held ward rounds at 10pm each night with the RMO and nurse.

We observed theatre teams undertook the ‘five steps to safer surgery’ procedures, including the use of the World Health Organization (WHO) checklist. The theatre staff completed safety checks before, during and after surgery and demonstrated a good understanding of the ‘five steps to safer surgery’ procedures. The service audited compliance for completion of the WHO checklist and data shared by the service showed consistent compliance.

Patients received a pre-operative assessment to identify key risks and their needs and preferences. Risk assessments were reviewed regularly or if there had been any change to a person’s condition. Where risks where identified, even on the day of surgery, this was thoroughly assessed and the procedure cancelled if assessed as unsafe.

Patients risks were discussed during daily safety huddles and as part of monthly multidisciplinary reviews involving the consultants and dietitians. Patient records we looked at showed staff appropriately recorded NEWS2 scores and included risk assessments for VTE, pressure ulcers, nutritional needs and risk of falls.

Patients told us the environment was safe, the design and condition of the rooms were good and met their needs. They said that the hospital areas and inpatient rooms were clean and that the equipment looked new.

The preoperative assessment area, ward and theatre areas were visibly clean, well maintained and free from clutter.

Equipment was visibly clean and well maintained. Staff told us that all items of equipment were readily available and any faulty equipment was repaired or replaced in a timely manner. We observed documents that showed the service recorded and monitored when equipment had been serviced and repaired. The service provided evidence of staff training in the use of clinical equipment and non-clinical equipment.

Staff told us they had no concerns regarding the building or environment. We were shown areas of the building that were being renovated and plans for service expansion which were under way.

There were daily cleaning schedules and deep cleaning every 6 months. Staff carried out daily safety checks of specialist equipment. Emergency resuscitation equipment was available in all the areas we inspected and we saw that daily and weekly equipment check logs were complete and up to date in those areas. All the emergency resuscitation trolleys we saw were tagged to minimise the risk that items could be tampered with. Resuscitation trolley audits over the past three months showed consistent resuscitation trolley maintenance compliance.

All equipment was tested annually around February and all new equipment was tested immediately regardless of when it arrived. It was then tested again in February.

The facilities lead was located on site and was responsible for managing facilities and equipment. We observed up to date risk assessments and associated action plans. This included fire safety, ventilation, legionella flushing of water outlets and environmental risk assessments including theatre and wards.

We looked at the hospital risk register and it showed that risks were recorded, reviewed and had actions in place to mitigate the risk. The highest risk was the replacement of theatre lights. Actions were well documented and was about to be removed as their fitting was imminent. Other risks were low and included a broken call bell in theatre, however they had the use of radios in the interim period while awaiting repair.

The service had a management plan in place for the prevention and management of unplanned and emergency situations.

There were arrangements in place for the handling, storage, and disposal of clinical waste, including sharps. The service complied fully with the Control of Substances Hazardous to Health (COSHH) practices.

Patients told us there were enough staff during and after their procedures and they provided safe care and treatment. They spoke positively about the way staff communicated and interacted with them and told us staff responded quickly when they requested assistance.

We saw that staff were available throughout the day to respond to patients in a timely manner.

We observed that staff delivered positive interactions with patients and worked efficiently together. We saw many staff around the hospital throughout our on site activity and all engagement we observed was positive, friendly and encouraging.

During the assessment we saw from the staffing rota and our observation that staffing in theatre and on the ward was sufficient and safe. Staffing levels were in line with the Association for Perioperative Practice (AfPP) and were based on the ‘safer staffing’ acuity tool. This meant staffing levels could be adjusted daily according to the number of patients and their needs.

The ward and theatre managers carried out daily staff monitoring and escalated staffing shortfalls as part of the daily hospital-wide and departmental huddles.

The vacancy rate was low and we heard that staffing was not an issue as they planned ahead and were always approved by the leadership team to obtain extra staff when required.

The service had enough medical staff to keep patients safe. Surgical procedures were carried out by a team of consultant surgeons and anaesthetists who were mainly employed by other organisations (usually in the NHS) in substantive posts and had practising privileges with Kinvara Private Hospital. The process for review of practising privileges ensured consultants were practising within their scope of practise.

Patients were reviewed by a consultant daily and were available for advice or further reviews throughout.

Staff received and kept up-to-date with their mandatory training. The mandatory training was comprehensive and met the needs of patients and staff. The head of clinical services had oversight of compliance and supported staff with their training needs. Compliance with mandatory training was high. Data provided by the service showed that the majority of staff were 100% compliant, however all staff were above the service target of 80% compliant.

We reviewed mandatory training compliance data for consultants, which showed just below the service target at 78% compliance, however they were all within their 1 month grace period.

Data provided showed that 100% of all required staff had completed advanced life support (ALS) and immediate life support (ILS) or were booked on to the course. Basic life support (BLS) training had also been completed by all required staff.

All staff, including bank and agency staff received a full induction tailored to their role before they started work. All consultants were invited to visit the hospital several times ahead of commencing work and were sent all policies to review. They were also invited to the Medical Advisory Committee (MAC) at least annually.

Staff told us they received annual appraisals and the service monitored compliance. The compliance with annual appraisals for all staff groups was 100%. The service recorded and monitored when doctors and consultants working under practicing privileges had completed appraisals with their own organisations (usually an NHS trust).

The provider’s recruitment policy outlined the recruitment and fit and proper person checks carried out for new staff, including for agency staff. We looked at a selection of staff recruitment files. These showed appropriate recruitment and pre-employment checks had been carried out.

Patients told us the premises and equipment were visibly clean and tidy, and they did not have any concerns relating to the cleanliness of the environment and equipment.

The service had infection prevention and control (IPC) policies which guided staff on processes and practices such as hand hygiene, cleaning of the perioperative environment and isolation of patients with known or suspected infections. Staff we spoke with told us they were aware of these policies and knew how to access them.

The service had an IPC lead who oversaw infection control processes and provided support for staff. Staff told us they had received training in IPC and hand hygiene.

Staff understood the processes for managing risks related to SSI’s (Surgical Site Infections). Staff told us they routinely monitored and escalated any suspected SSI’s to the managers and to the medical staff so patients could receive appropriate treatment and transfer to hospital if required.

The service undertook regular IPC audits to monitor compliance with hand hygiene and general IPC principles including the environment and equipment.

Audit results for the ward and theatre areas showed compliance for hand hygiene was consistently 100% between September 2024 and August 2025. Audit results for the PPE audit, waste management and standard precautions were all at 100% compliance at the time of our assessment.

The preoperative assessment area, ward and theatres were visibly clean and had suitable furnishings which were clean and well-maintained. Cleaning schedules were in place with clearly defined roles and responsibilities for cleaning the environment and cleaning and decontaminating equipment.

Patients were screened for infections such as Methicillin-resistant Staphylococcus Aureus (MRSA) and the service had isolation rooms to support the management of cross infection risks. There had been no cases of MRSA or Clostridium difficile (C.diff) infections at the hospital for the previous 12 months.

There were enough hand wash sinks and hand gels. Patients and visitors were encouraged to wash their hands. We observed staff following hand hygiene and 'bare below the elbow' guidance appropriately. Staff were observed wearing personal protective equipment, such as gloves and aprons, while delivering care. Gowning procedures were adhered to in the theatre areas. Clean linen was appropriately stored and segregated in dedicated storage areas.

The service conducted surveillance of surgical site infections (SSI’s) and each incident was reported and investigated to look for improvements. Data provided by the service showed that 12 SSI’s had been reported between August 2024 and August 2025. These varied by month and consultant.

All documented infections were treated with antibiotic therapy. The majority treated with oral antibiotics, 1 case required emergency department referral and 1 case involved specialised knee aspiration. All identified surgical site infections received appropriate clinical intervention with antibiotic therapy. Cases were managed through various healthcare providers including hospital services, general practitioners, and emergency departments as clinically indicated.

The data demonstrated active surveillance and reporting of surgical site infections across all surgical services, with detailed documentation of patient identifiers, infection types, treatments, and outcomes.

Staff followed national best practice to check patients had the correct medicines when they were admitted to the hospital. There was no pharmacy on site, however the service had an agreement with a local pharmacy for advice and input into anaesthetic and perioperative assessment was available on request. Medicines administration records were clearly presented and up to date. On discharge patients were given verbal and written information about what to do and whom to contact if for example, they were unsure how to take their medicines or manage any side-effects. Discharge letters were sent to patients GPs so that records could be kept up to date.

The provider had effective systems to manage and respond to safety alerts and medicine recalls.

There was a programme of regular medicines audits to help ensure hospital policy was followed in practice. Prescription stationery was securely managed. Medicines including controlled drugs were stored safely and securely at appropriate temperatures.