Orpington Endoscopy Centre

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• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

This means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

At our last assessment we rated this key question as good. At this assessment, the rating has remained good. This meant people consistently received effective care and treatment that supported good clinical outcomes.

The service assessed, planned and reviewed care in line with patients’ needs and evidence-based guidance. Staff monitored outcomes through audit and national benchmarking, worked effectively with other professionals and services, and used learning to improve practice. Patients were supported to make informed decisions through clear consent processes and were provided with information to support treatment, recovery and healthier lives.

We have not awarded this service a score for Effective.

Find out about when we will not publish a key question score and what we look at when we assess Effective.

The service assessed patients’ needs and planned care in line with identified clinical risks and individual requirements.

We reviewed 10 patient records. We observed that records contained referral information, pre-assessment documentation, World Health Organisation (WHO) safety checklists, procedure reports and discharge documentation. Records demonstrated that health assessments were completed before procedures were undertaken and included relevant medical history, clinical risks and communication needs. In 1 record, staff identified that a patient required language support and arranged interpreter assistance to support assessment and treatment.

We observed that care planning reflected patients’ assessed needs. Records contained procedure-specific documentation, clinical findings, treatment plans and discharge arrangements, demonstrating that assessment findings informed care delivery throughout the patient pathway.

We observed that care records reflected patients’ individual circumstances, including medical history, communication requirements and recovery needs. Documentation demonstrated that information and support were adapted where required to meet individual needs.

We observed that records were maintained and updated throughout the patient pathway. Records included completed assessments, procedural findings, discharge documentation and follow-up arrangements where necessary, providing evidence that patient information was reviewed and updated as care progressed.

Data provided by the service showed there were documented admission criteria in place to support the assessment of patients before admission. The criteria set out inclusion and exclusion requirements and identified patient groups and clinical risk factors that required referral to an acute hospital setting. This supported a consistent approach to determining whether patients' needs could be safely met by the service.

The service delivered care and treatment in line with evidence-based guidance and used audit and quality assurance processes to monitor practice. Staff worked to Joint Advisory Group standards; British Society of Gastroenterology guidance and local policies aligned with national requirements.

Patients received information about preparing for procedures, including fasting, sedation, recovery, post-procedure care and when to seek medical advice. Digital information and consent resources were available before treatment. Patients were offered refreshments during recovery and received advice about eating and drinking after discharge.

The service participated in clinical audit and benchmarking through the National Endoscopy Database (NED). It monitored caecal intubation and polyp detection rates, bowel preparation quality, patient comfort and sedation practice.

Consultant performance and endoscopy outcomes were reviewed through governance processes. Consultants reviewed their individual NED data as part of annual appraisal, with six-monthly reviews used to identify performance outliers. Outcome data was also reviewed at three-monthly governance meetings attended by consultants.

WHO audit results showed 100% compliance with documentation and observation measures in July 2026. In August 2026, observation compliance and documentation completion remained at 100%; however, documentation compliance decreased to 87%, below the provider’s 95% target. The service did not provide an action plan showing how it would address the reduced documentation compliance or monitor improvement, so we could not be assured that the shortfall had been identified and effectively managed.

Actions arising from Joint Advisory Group accreditation (JAG) reviews included changes to service delivery, staff training and patient pathways. JAG re-accreditation was in progress at the time of this assessment.

The multidisciplinary team (MDT) included consultant gastroenterologists, endoscopists, Registered Nurse (RN), Healthcare Support Worker (HCSW) and decontamination staff. Patients requiring specialist input or higher-acuity care were referred to acute hospital services in line with the service’s admission criteria.

Consultants participated in appraisal and mandatory training. Staff completed mandatory training and role-specific competencies, assessed through direct observation, standard operating procedures (SOPs) and JAG aligned assessments. In July 2026, all 6 staff recorded on the appraisal monitoring system had completed an appraisal, which included review of mandatory training, objectives and development needs.

Managers monitored staff and consultant practice through appraisals, practising privileges, competency reviews and governance processes. Staff had access to 1-to-1 meetings, departmental meetings and after-action reviews, where learning from incidents, complaints, compliments and audits was shared. Escalation arrangements were in place where performance or patient safety concerns were identified.

The service worked effectively with internal and external teams to coordinate care, share information and support patient outcomes.

We observed that staff participated in regular MDT and governance meetings to review quality, safety, incidents, complaints and service performance. Consultants attended 3-monthly governance meetings where learning and performance information were discussed and shared across the team. Staff also described monthly departmental meetings, satellite governance meetings and regular team communications to support oversight and learning.

We observed evidence of regular team huddles involving clinical and operational staff. Team huddles were used to discuss daily activity, staffing, operational issues and any immediate concerns. Staff also described using team briefings to share audit findings and learning from incidents and governance activity.

We observed that information was shared effectively between staff involved in patient care. Recovery staff described receiving handovers from consultants and using procedural information, patient observations and clinical instructions to support recovery and discharge decisions. Staff were clear about escalation arrangements and their responsibilities if concerns arose during a patient's care.

We observed effective working relationships between MDT. Staff described a collaborative approach to care delivery and MDT working across the service. Administrative and nursing teams worked together to coordinate referrals, pre-assessments, appointments and procedure preparation.

The service supported patients to make informed decisions about their health and promoted healthy lifestyles through the provision of evidence-based information and education.

We observed that patients were provided with condition-specific information to support understanding of gastrointestinal conditions, treatment options and ongoing self-management. Information available to patients covered bowel cancer, Barrett’s oesophagus and diverticular disease and included guidance on symptoms, risk factors, treatment pathways and when to seek further medical advice.

The service promoted cancer awareness and early diagnosis. Patient information included advice on recognising symptoms of bowel cancer, the importance of early detection and participation in national bowel cancer screening programmes. Information was also provided about Faecal Immunochemical Testing (FIT) and referral pathways for further investigation where required.

Patient information highlighted modifiable risk factors associated with gastrointestinal disease, including smoking, alcohol consumption, obesity, poor diet and physical inactivity. Advice was provided on smoking cessation, healthy eating, weight management, increasing fibre intake where appropriate and regular exercise.

Patients were also signposted to specialist charities, support groups and additional sources of evidence-based information to support ongoing health management and informed decision-making.

The service monitored patient outcomes and used audit, technology and recognised tools to support the delivery of safe and effective care.

Staff used recognised tools to identify and respond to clinical deterioration. Records included completed WHO safety checklists, pre-assessment documentation, physiological observations and recovery monitoring. SOPs and escalation pathways supported staff to recognise and manage deterioration.

The service monitored clinical outcomes through the NED. Endoscopist performance was reviewed against national indicators, including caecal intubation and polyp detection rates, bowel preparation quality, patient comfort and sedation practice. Clinical lead reviews recorded outcomes as satisfactory across the practitioners audited.

The audit programme covered NED outcomes, post-colonoscopy colorectal cancer, patient satisfaction, medicines management and nursing documentation. Results were reviewed at staff, user group and clinical governance meetings to support learning and improvement.

Electronic endoscopy reporting, NED benchmarking and audit tools supported performance monitoring, outcome tracking and governance oversight. Electronic traceability systems supported quality assurance.

The service obtained consent in line with legislation and national guidance and supported patients to make informed decisions about their care and treatment.

Patients received verbal, written and digital information about the procedure, its benefits, risks, alternatives and the option of no treatment. Consent was treated as an ongoing process and reconfirmed before the procedure. Procedure-specific digital resources supported informed decision-making.

Staff supported patients to make their own decisions by providing accessible information and arranging interpreters where required. Policies reflected the principle that capacity should be presumed unless established otherwise and required staff to take practical steps to support decision-making.

Staff assessed mental capacity where there were concerns about a patient's ability to consent. The service used the Communicate, Understand, Retain and Balance (CURB) assessment process and completed assessments on a decision-specific and time-specific basis in accordance with the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS). Where patients lacked capacity, decisions were made in their best interests. Policies required involvement of family members, carers, advocates and Independent Mental Capacity Advocates (IMCAs) where appropriate. Best interest decisions considered the person's wishes, feelings, beliefs, values and cultural needs and were recorded using formal documentation.

Data provided by the service demonstrated oversight of consent practice through regular audit. Consent form completion was 100% in both June and July 2026. Compliance with consent standards was 90% in June due to one consent form missing a date and improved to 100% in July, meeting the service target.