The New Foscote Hospital

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We looked for evidence that safety was a priority for everyone, and leaders embedded a culture of openness and collaboration. We checked that people were safe and protected from bullying, harassment, avoidable harm, neglect, abuse and discrimination. We also checked people’s liberty was protected where this was in their best interests and in line with legislation.

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

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 honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Staff understood what an incident was and how to report it. The service had an incident reporting policy, which was up-to-date and thorough. The policy included information on the Duty of Candour (the NHS Duty of Candour is a legal obligation for healthcare providers to be open, honest, and transparent with patients and families when things go wrong with care). The policy also referred to the Patient Safety Incident Response Framework (PSIRF). PSIRF is the NHS England mandated, systematic approach for responding to patient safety incidents. It shifts focus from accountability to learning, emphasising compassionate engagement with affected families and staff, proportionate responses, and system-based investigations to improve safety.

The services used an electronic incident reporting system to record incidents, however only a small number of managers had access to the system. When a manager was unavailable, staff completed a paper incident form which was later uploaded to the electronic system by a manager. Managers ensured incidents were reported in a timely manner and that all relevant information was included. Staff were encouraged to raise concerns with managers and described an open culture where issues could be escalated promptly. Managers reviewed incidents to determine whether further investigation was required. Where necessary, managers worked with the team leader to undertake investigations and identify any learning.

Following any incident, the endoscopy team met to discuss the event and any learning identified. The provider also shared learning electronically with all hospital staff to ensure they disseminated learning across all services. Senior leaders gathered for a daily huddle every weekday. As part of this, they discussed incidents and actions taken to investigate and mitigate risk. Following every huddle, a staff member sent meeting minutes to all hospital staff via email, which included information on incidents.

The governance team led on all incident investigations. The focus was to remain as independent as possible. We heard it was “really important that you take the fear away from staff, there is no blame”. Governance staff involved departmental leads in any investigation.

The governance team recorded actions, investigations, dates and roles of staff involved in the incident. The system allowed for an audit trail of activity and notifications and reminders.

We reviewed the incident log and saw there had been no incidents recorded specific to endoscopy since January 2025.

We scored the service as 3. 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 people moved between different services.

The provider had clear inclusion and exclusion criteria for endoscopy. The endoscopy service only carried out elective procedures and did not accept emergency admissions. Every patient had to complete a pre-assessment form prior to any procedure. The clinical team discussed the completed form with patients during a pre-procedure appointment. The endoscopy service ensured patients understood and could consent to the procedure. For patients who lacked capacity to consent, there were appropriate processes to support decision-making, assess capacity, and obtain lawful consent in line with relevant legislation and guidance.

The provider had a discharge policy, which outlined the process of ensuring a safe discharge. Discharge planning started as part of the pre-admission assessment which ensured identification of potential problems or needs before treatment started. The service ensured patients were involved in their discharge planning. The policy also clearly outlined necessary actions for patients being transferred to other healthcare providers. This included communication with the relevant receiving provider prior to discharge.

If there were concerning findings identified during a procedure, we were told the team held a discussion to decide the next steps. The lead clinician and the surgeon usually spoke with the patient to explain the outcome of their investigation and next steps, for example onward referrals to other services for further investigation or treatment. Staff encouraged patients to contact the department after discharge if they had any questions or concerns.

We scored the service as 3. 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.

Staff knew how to identify safeguarding concerns. They could identify what types of concerns required police involvement or a referral to the safeguarding lead and outside agencies. Staff knew when to escalate care concerns to the patient’s GP.

The provider had a safeguarding adults and children policy in place which was in date and met the requirements of the intercollegiate guidelines. The policy clearly outlined types of abuse, staff roles in identifying and reporting any concerns, and routes of internal and external reporting. The policy referred to legal safeguarding frameworks, such as The Mental Capacity Act 2005 and the Department of Health safeguarding guidance.

Every staff member received level 3 training in safeguarding adults and children. The endoscopy service currently employed 5 members of staff and all of them were up to date with their adult safeguarding training. One hundred per cent of staff had completed the safeguarding of children module. The provider also covered safeguarding adults and children during the induction of new staff members.

All staff received training related to disability and learning disabilities awareness, autistic spectrum disorders, female genital mutilation and the Mental Capacity Act appropriate to their role.

The provider had a named safeguarding lead covering the whole service who was trained to level 4. We saw posters across the site displaying who the safeguarding lead was.

The provider had a chaperone policy in place, which was up to date and outlined how patients’ dignity and privacy would be safeguarded, together with how staff were protected from any allegations of inappropriate behaviour.

Evidence provided showed there had been no safeguarding referrals made to external agencies in the 12 months prior to our inspection.

We scored the service as 3. 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.

All patients met with clinical staff to go through their treatment plan, ahead of any endoscopic procedure. This appointment included discussions around treatment options, any risks associated with procedures, and consent. At this stage, patients with any additional risk factors could be identified and treatment planned with particular risks in mind.

The endoscopy team met every morning to discuss the day ahead. This ensured they knew patients and procedures for each day and could discuss any known risk or patient story in real time

The service used an adapted version of the World Health Organisation (WHO) surgical safety checklist for all procedures (this is a 3-phase tool designed to reduce errors and improve patient safety. It consists of the sign in (before sedation or anaesthesia), time out (immediately before the actual procedure begins), and sign out (final checks before the patient leaves the endoscopy room). We observed a procedure and saw that staff carried out all required checks thoroughly and at the appropriate times.

Staff monitored patients’ pain throughout the procedure and gave pain relief where necessary. Staff knew what to do if a patient deteriorated. The small size of the unit and closeness to other units meant senior support was readily available. Staffing levels allowed for close monitoring of each patient and a rapid response to any changes. The endoscopy unit had access to emergency equipment in the clinic room and in a corridor nearby. Staff underwent regular scenario-based training using mannequins; for example, to practise cardiopulmonary resuscitation.

The service had links with a local NHS trust in case patients needed to transfer to an acute hospital with complications. In the period between January to December 2025 this had only occurred once.

Staff knew what to do if a patient withdrew their consent. Even if this occurred within minutes of the procedure starting, they immediately stopped.

The consultant informed patients of any abnormal findings or post procedure complications and signposted them accordingly. For example, if staff observed an abnormality during a colonoscopy, they signposted the patient to a colorectal or oncology department. Every patient received a follow-up telephone call the day after discharge to ensure staff monitored any post-procedural problems.

We scored the service as 2. The service did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

Staff told us the service conducted daily and monthly equipment stock checks in the endoscopy clinic room. The monthly stock check included checking expiry dates and rotating stock. We checked many storage units containing medical equipment and found many items were out of date, some by over one year. Expired medical consumables are a risk as they may no longer be sterile, break down, or cause infection.

We informed the service manager who immediately disposed of out-of-date items. Following the inspection, we received communication to let us know a new stock check system had been introduced to ensure this did not happen again.

The housekeeping team had use of a room within the endoscopy unit. The door to this room was unlocked and easily accessible. Within the room we found hazardous chemical items, such as bleach and floor cleaner. These are covered by the Control of Substances Hazardous to Health (COSHH) regulations and should be risk assessed and stored safely. We saw completed risk assessments of all items; however, staff did not store items safely as the door was unlocked. Although this room did not form part of the endoscopy service, its location meant anyone visiting the unit could access the room. Following the inspection, the provider reviewed the existing arrangements and implemented additional measures to further strengthen security. A locked COSHH cabinet has now been installed within the room to ensure that cleaning chemicals and products are stored securely, with access restricted and appropriately controlled.

Each patient room had a toilet, handwashing sink and shower room, along with a television and a lockable cupboard to store belongings. We saw oxygen cylinders in each patient room; however, staff had not secured each of the cylinders with the strap provided. This is important to ensure they are protected from damage or tampering. All oxygen cylinders were in date.

The provider had recently introduced a new asset management system. This included all assets, for example, medical and non-medical equipment, doors, beds, and ventilation. Staff accessed the system with their mobile phone by scanning a barcode on the piece of equipment they wanted to check. They saw immediately when an item was last tested and serviced. The asset management system was still in the testing phase. We heard it would be ready to use in 6 months’ time.

Staff kept the endoscopy unit tidy and clutter free. Following a procedure, we observed staff cleaned the clinical area as soon as a patient had been moved to another room to recover. Housekeeping staff cleaned patient rooms upon discharge.

The service had a procedure for processing biopsies taken during an endoscopic procedure. They used an external laboratory who picked up samples on the day. The laboratory provided reports regarding their analysis of samples electronically. Usually, the endoscopy service received electronic alerts of laboratory reports quickly.

The service now had an on-site decontamination facility. Flexible endoscopes and surgical instruments underwent cleaning as recommended by NHS England. We observed a clear pathway for dirty equipment. This followed a strict one-way flow to prevent cross-contamination. Currently the provider used a handwritten logbook for traceability; however, they were in the process of looking into an electronic log to save time. The decontamination facility had clean and dirty areas with suitable personal protective equipment (PPE) available. Once staff completed the sterilisation process, they vacuum bagged equipment and sent it back to endoscopy room.

Staff carrying out the procedure had received online and Joint Advisory Group (JAG) on gastrointestinal (GI) Endoscopy accredited training. We observed the service was fully compliant with NHS England’s Health Technical Memorandum.

The provider continued their decontamination contract with the local NHS hospital trust as a back-up if needed.

The provider followed NHS England’s guidance of sending weekly water samples from their endoscope reprocessors to a lab for final rinse water sampling (a reprocessor is a specialised medical machine that automatically cleans and disinfects flexible endoscopes between uses). This was essential to confirm the absence of contamination after disinfection.

The provider used a third-party company to carry out all annual quality validation and maintenance of their endoscope equipment and machines. The company would visit at short notice to rectify any issues identified with equipment or machinery.

Staff had access to emergency equipment. The trolley was located next to the endoscopy area. On review it was fully stocked with the appropriate equipment, all of which was in date. Staff members knew where the trolley was located. Audits showed the trolley was checked daily.

The provider stored medical gases securely in an outside locked storage facility.

We scored the service as 3. The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. Staff worked together well to provide safe care that met people’s individual needs.

The endoscopy service had sufficient numbers of suitably skilled, qualified, trained and experienced staff. We heard from leaders the provider now had a core group of established staff and did not need to use agency staff in endoscopy. All clinical staff were multiskilled and could cover all areas. For example, if the endoscopy unit needed additional staff, they asked for support from the ward or theatres first. They used bank staff if needed although this had not been necessary for almost one year.

Actual staffing in the service aligned with planned staffing. We reviewed data from April 2025 to March 2026 and saw that, apart from April 2025, actual staffing either matched or exceeded planned staffing. The provider had a safe cover arrangements policy in place, which outlined how and when to raise staffing issues and how to source staff if needed. Every weekday morning, leaders met at a huddle during which they discussed any staffing gaps.

All staff completed mandatory training relevant to their role. We reviewed the training data and the compliance of endoscopy staff was 94%. The provider offered in-house and external training. The Human Resources (HR) department monitored staff training compliance using an electronic HR system. The system flagged staff who needed to update their training. We saw parts of the electronic system and found it comprehensive and intuitive.

Although clinical supervision was not a formal process, staff told us they had ample opportunity to access support from their manager. The service had daily huddles and end of day debriefs, which served as supervision if needed. This was possible due to the small size of the team and managers responded to their team in real time.

Staff received regular annual appraisals. New starters had check-ins at 1 week, 4 weeks, 3 months, 6 months and 12 months. All new staff attended an induction relevant to their role.

The provider ensured they carried out thorough checks when recruiting new people. We looked at 4 random staff records and saw all checks had been completed: for example, the Disclosure and Barring Service (DBS) checks, passports and references. As part of the interview stage, the provider offered a ‘work trial’ to observe potential staff under supervision. This offered both the provider and the applicant an opportunity to see if they had the potential to be employed. One manager told us, “I am proud of saying we want the best of the best to work here”.

The endoscopy service had very low vacancy, sickness, and turnover rates. There had been no cancelled procedures due to a lack of medical or nursing staff in the data we reviewed from January 2025 to March 2026.

The endoscopy service was currently undergoing JAG on GI Endoscopy accreditation (this is awarded to endoscopy services that have undergone a formal assessment and demonstrated that they meet the JAG quality standards). As part of this, all staff underwent a structured approach to evidence skills and competencies and achieve certifications.

We scored the service as 3. 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.

Staff ensured they kept the endoscopy unit clean, tidy and well maintained. Every door to the clinic room and patient rooms displayed a cleaning log, which was completed after every clean. The service conducted daily end of list checks to ensure the environment and equipment was clean. We reviewed 3 checklists, all of which had been fully completed.

The service had a comprehensive and up-to-date infection and prevention control (IPC) policy. This comprised of information on general, clinical and personnel safe practice guidance.

The service undertook IPC audits in accordance with the provider’s annual audit programme. We reviewed the audit plan, which included the areas to be reviewed, the frequency of audits, the responsible lead and a description of what was to be reviewed. The clinical governance and IPC committees reviewed audit results at their meetings.

All staff received IPC training and role-specific competencies, such as aseptic non touch techniques and decontamination.

The endoscopy facilities were compliant with the Department of IPC regulations. Staff had access to personal protective equipment (PPE), including hand gels and disinfectant wipes. Each patient room had its own handwashing sink, with hand gel available. Above each sink the service displayed posters with instructions for handwashing. We observed staff carried out appropriate hand hygiene procedures.

The service was compliant with NHS England’s health technical memorandum relating to the safe management and disposal of healthcare waste.

We scored the service as 3. The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happen.

The provider had 2 policies specifically related to the management of medicines. Both policies referred to relevant legal frameworks and guidance, for example, the Human Medicines Regulations 2012 and the National Institute for Health and Care Excellence (NICE). These policies clearly outlined roles and responsibilities of staff, stock management and monitoring, and appropriate storage of medicines.

The provider had an on-site pharmacy. We reviewed the medicines stockroom and found all medicines were in date and stock rotation took place (stock rotation is a process of organising the inventory to ensure medicines with the earliest expiration dates are dispensed first, while newer stock is placed at the back).

Patients received pain relief if required. Staff checked if patients were comfortable and then prescribed, administered and recorded pain relief accurately, if needed. Clinicians used local anaesthetic spray to numb throats prior to a gastroscopy. Patients could receive sedation if required.

Endoscopy staff checked their CD stock twice a day and pharmacy conducted spot checks as well. Controlled drugs were checked in accordance with national guidance.

The service disposed of medicines correctly. Staff emptied liquid medicines and infusion bags, removed tablets from their foil strips and placed everything in a destruction kit to be sent for incineration.