Orpington Endoscopy Centre

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 people were protected from abuse and avoidable harm.

At our last assessment, we rated this key question as good. The rating remains good. This meant people were protected and kept safe.

The service managed risks to patients and staff, maintained a clean and well-maintained environment, completed equipment checks, and managed medicines safely. Staff understood how to recognise, report and escalate safeguarding concerns and had access to guidance and referral pathways to support decision-making. The service promoted a positive learning culture where incidents were reported, investigated and used to support improvements in practice. However, some staff were unable to identify the safeguarding leads or describe how to contact them directly.

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.

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.

The service reported no serious incidents resulting in harm during the review period. Incident records included equipment failures, staffing pressures, stock management issues, patient experience concerns and information technology failures. All incidents reviewed were recorded as causing no harm to patients or the organisation. Staff reported both clinical and non-clinical incidents, demonstrating awareness of reporting processes and escalation requirements. The service had an incident reporting policy in place. Incidents were investigated promptly, with learning and actions identified to reduce the risk of recurrence. Learning was shared with staff through team huddles, briefings, debriefs and emails.

Staff understood the duty of candour. After a delayed pre-assessment appointment, they apologised to the patient, explained the reason for the delay and contacted them directly to discuss their concerns. The patient returned later that day and completed the assessment. The service reported that there had been no duty of candour cases during the review period.

Incident investigations identified learning and actions to reduce the risk of recurrence. Following a missing gastric balloon filler kit, the service introduced regular stock checks and strengthened stock monitoring processes. Following concerns about staffing levels, the service reviewed staffing establishments and staff competencies to ensure they met service requirements and recognised endoscopy standards.

There was evidence that learning resulted in service improvements. Equipment failures were escalated and repaired promptly, including decontamination equipment and refrigeration units, to minimise disruption to patient care. Following delays in pre-assessment clinics, the service identified the need to review activity planning to reduce the risk of future delays. Team briefings, huddles and debriefs were used to discuss incidents, share learning and support staff following significant operational events.

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 service had clear admission and exclusion criteria to ensure patients were suitable for treatment within the standalone endoscopy unit. Patients accepted for treatment were limited to adults aged 18 years and over, undergoing low-risk, low-complexity procedures and assessed as American Society of Anaesthesiologists (ASA) grade 1 or 2, which indicates patients who are healthy or have mild, well-controlled systemic disease. Patients assessed as American Society of Anaesthesiologists (ASA) grade 3, meaning those with severe systemic disease and greater procedural risk, and patients with more complex needs, were not routinely accepted for treatment. Patients whose clinical needs exceeded the service's admission criteria, including those requiring a general anaesthetic, were referred to their local district general hospital where their care could be managed safely.

Pre-assessment identified patients requiring additional review, and those with complex needs outside the admission criteria were referred to an appropriate service. Leaders told us therapeutic procedures had ceased because suitable escalation arrangements were unavailable if complications occurred and only 1 consultant had previously performed them. Activity was therefore limited to lower-risk procedures, including gastroscopy, colonoscopy, flexible sigmoidoscopy, capsule endoscopy and removal of polyps smaller than 2 centimetres.

Staff described structured referral and booking pathways for both NHS and private patients. Private patients were assessed by consultants before referral to the endoscopy service and were booked into pre-assessment before their procedure. NHS patients underwent pre-assessment before procedural booking. Staff confirmed that medication reviews, bowel preparation requirements and pre-procedure information were managed through the nursing team to ensure patients received appropriate clinical assessment and preparation before treatment.

The service had arrangements to support continuity of care following discharge. Recovery staff completed post-procedure observations, followed discharge protocols and provided patients with procedure reports and discharge advice. Patients received information about post-sedation restrictions, potential complications and who to contact if concerns arose after discharge. Staff told us that patients considered vulnerable following sedation could receive a follow-up telephone call the following day to check on their recovery and wellbeing.

Staff involved other healthcare services when required to support safe care. Patients requiring a higher level of care or whose needs fell outside the service’s admission criteria were referred to local acute hospitals. Procedures were in place to recognise and escalate clinical deterioration. Staff used the National Early Warning Score 2 (NEWS2), the Situation, Background, Assessment, Recommendation (SBAR) and decision communication tool to escalate concerns, and sought urgent review from a medical officer or consultant and arranged emergency ambulance transfer when required. Following discharge, patients were advised to contact their General Practitioner or attend the Accident and Emergency department if concerns arose. Staff escalated safeguarding concerns to managers and consultants through established processes.

The service worked with people to understand and protect them from abuse, discrimination and avoidable harm. Staff understood safeguarding processes and knew how to raise concerns appropriately.

Staff received safeguarding training appropriate to their roles. Training compliance was 100% for safeguarding adults’ levels 1, 2 and 3. Staff had also completed safeguarding children’s levels 2 and 3 training to support the management of situations where patients attended the service with relatives aged under 18 years.

Staff understood how to identify and protect patients at risk of abuse, harassment, discrimination and avoidable harm, including people with protected characteristics under the Equality Act 2010. Staff were aware of the safeguarding policy, understood how to make safeguarding referrals and described escalating concerns to managers and consultants. An up-to-date safeguarding policy, aligned with national guidance, was provided through corporate and organisational support from a hospital. Staff also had access to safeguarding flowcharts containing local authority referral pathways and contact details.

Safeguarding lead responsibilities were provided through wider organisational arrangements, with senior staff responsible for supporting the service. Safeguarding information was communicated through established local and organisational governance processes, and contact details were displayed within the department. However, some staff were unable to identify the safeguarding leads or explain how to contact them directly, although safeguarding contact details were displayed within the department. Following post-inspection feedback regarding staff awareness of safeguarding leads, the service appointed the centre operations manager to its safeguarding team, providing staff at satellite sites with a local point of contact.

The service worked with people to understand and manage risks holistically. Staff provided patients with information to support informed decision-making and involvement in their care and treatment.

During booking and pre-assessment, staff recorded patients’ relevant medical history, current medicines, allergies, communication needs and individual clinical risks. Staff used this information, together with the service’s admission and exclusion criteria, to determine whether patients’ needs could be safely met and whether additional support or referral to another service was required. Before procedures, staff involved patients in confirming their identity, allergies, medical history, consent and procedure-specific risks through the World Health Organisation (WHO) Endoscopy Safety Checklist.

Patients received written, verbal and digital information about their procedures, including the benefits, risks, alternatives and preparation requirements. Staff identified communication needs during booking and pre-assessment and arranged interpreter services, hearing loops or other reasonable adjustments where required. Procedure-specific information supported the digital consent process, and patients could ask questions, decide not to proceed or withdraw consent at any stage.

Patients were provided with condition-specific and procedure-specific information leaflets covering investigations, treatment options, risks, follow-up arrangements and sources of support.

The service sought patient feedback through satisfaction surveys and feedback on the information provided before treatment. The operational policy stated that patient feedback was reviewed and used to support service improvement. For example, feedback about reception waiting times, fasting instructions and pre-procedure communication led the service to provide more frequent updates in reception, give fasting instructions verbally and by email, and introduce additional checks to confirm patients had received the required information.

The consent process supported patients to make decisions about their care, including refusing treatment or withdrawing consent. Information leaflets also provided details of external support organisations. However, we did not see evidence of information relating to access to independent advocacy services in the documents reviewed.

The service maintained an environment and equipment’s that supported the safe delivery of care and treatment, although some environmental issues had been identified and were being addressed through an action plan.

The endoscopy unit was purpose-built and included patient bedrooms with en-suite facilities, recovery areas and procedure rooms. We observed a clear ward layout with no significant environmental risks identified. Designated fire exit doors and assembly points were in place to support evacuation in the event of an emergency. Leaders told us they had also attended an away day with the fire service, and the fire alarm system was linked to automatically notify the fire service when activated. Staff were also required to complete mandatory fire safety training every 2 years to support preparedness to respond to an environmental emergency. Patient flow from admission through to discharge was logical and supported privacy and dignity. Recovery areas were located within patient rooms, and procedure rooms were clean and appropriately equipped. Patient records were securely managed, with paper records scanned onto electronic systems before confidential disposal.

We observed that emergency and resuscitation equipment was readily accessible. The resuscitation trolley was appropriately stocked, clearly labelled and all sampled consumables, emergency medicines, oxygen, suction equipment and the defibrillator were available and in date. Equipment maintenance and servicing arrangements were in place and environmental audits confirmed that clinical equipment was subject to regular inspection and safety checks.

Environmental audits completed in July 2026 found that communal areas, patient areas, flooring, linen storage and clinical equipment were generally clean and in good condition. Water safety arrangements were in place, including monitoring of low-use water outlets. We also observed endoscope decontamination equipment, and storage facilities were maintained, with systems for traceability, validation and maintenance of equipment.

The service had identified a small number of environmental issues through its audit processes and had developed an action plan to address these. These included damaged corridor glazing panels, broken waste bins and clutter within some multi-purpose rooms which reduced available storage space.

During the assessment, we observed that 1 procedure room was not routinely in use because current activity levels could be accommodated safely within a single procedure room. Staff described plans to increase activity and confirmed environmental capacity was available should service demand increase. We also observed that an issue with the reverse osmosis water plant limited the ability to operate both endoscope washers simultaneously. Staff told us this had not affected service delivery due to current service utilisation and there were plans in place to resolve the issue.

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.

Staffing data showed a substantive establishment of 4.8 whole-time equivalent (WTE) staff, comprising a clinical lead, a Registered Nurse (RN), two Senior Healthcare Assistance (SHCA) and a decontamination lead. The consultant database recorded 10 consultants with practising privileges. The service reported one 37.5-hour-per-week clinical support worker vacancy, equivalent to a 17.2% vacancy rate. 2 substantive staff, 1 RN and 1 clinical support worker, had left during the previous 12 months. The sickness rate was 1.28%, based on 16 sickness days across the workforce.

Managers told us staffing levels were planned according to activity levels, patient needs and endoscopy guidance. Rotas were reviewed weekly and staffing was discussed through daily team huddles and briefings. We observed staffing levels being reviewed at the start of the day and managers told us staffing could be adjusted in response to activity and case mix.

Staff told us the service was operating with a shortfall of 2 WTE registered nurses. Managers and staff reported this was being managed using regular bank staff familiar with the service. Bank staff completed the same mandatory training and induction requirements as substantive staff. Staffing data confirmed bank staff were used to provide resilience where substantive staff were unavailable.

Medical cover was provided by consultants with practising privileges who undertook endoscopy lists and outpatient activity. Staff described clear escalation arrangements for deteriorating patients and emergency transfers, supported by consultant and senior management oversight.

Mandatory training compliance was 97.8% in August 2026. However, 4 training modules were below the provider’s 95% target: medical gases at 66.7%, moving and handling e-learning and clinical practical training at 80%, sepsis at 85.7%, and face-to-face basic life support at 87.5%. All other applicable subjects achieved at least 90% compliance. The service did not provide evidence of how compliance below the provider’s target was monitored or addressed, which reduced assurance that mandatory training shortfalls were identified and managed.

Staff received regular appraisals to support their performance and development. In July 2026, all staff and consultants recorded on the appraisal monitoring system had completed an appraisal. Appraisals included reviews of mandatory training, objectives and development needs.

The service assessed and managed the risk of infection. The service had systems and processes to prevent and control infection.

We observed staff following infection prevention and control (IPC) procedures throughout the patient pathway, including hand hygiene, use of personal protective equipment and cleaning of equipment between patients. Staff maintained separation of clean and dirty endoscopes and followed established decontamination processes. The operational policy set out requirements for cleaning equipment, treatment areas and patient equipment between procedures.

We observed clinical areas, equipment and furnishings to be visibly clean and well maintained. Equipment was cleaned after use, and clean equipment was clearly identifiable. Sharps bins were correctly assembled, labelled and managed in line with guidance. Cleaning records were maintained and demonstrated regular cleaning of clinical areas and equipment.

Service data showed 100% completion and compliance for hand hygiene audits in July and August 2026, while IPC audits also achieved 100% compliance. Sharps audit completion remained at 100%, with compliance increasing from 97.14% in July 2026 to 100% in August 2026.

The service had systems to monitor the safety of endoscope decontamination and storage. A traceability audit completed in March 2026 demonstrated all scopes reviewed could be tracked through the decontamination process and linked to individual patients. Annual validation reports confirmed the endoscope washer disinfectors and drying cabinet were operating within required parameters. Water testing completed in August 2026 demonstrated satisfactory microbiological results.

The service ensured medicines and treatments were managed safely and reflected people’s needs, capacity and preferences, in line with local policies and national guidance.

We observed staff following medicines management processes during endoscopy procedures. Before sedation, staff confirmed patient identity, allergies, medical history, sedation suitability and individual risks using the World Health Organisation (WHO) Endoscopy Safety Checklist. Sign-in, time-out and sign-out checks were completed before, during and after procedures. The service also monitored checklist compliance through its wider audit programme.

We observed sedation and analgesia being administered in line with patient need and service protocols. Monitoring equipment was in use, emergency equipment was available, and recovery requirements were communicated before patients left the procedure room. Medicines administered during procedures were recorded appropriately.

Medicines reconciliation formed part of the pre-assessment and admission process. Staff reviewed patients’ medicines, allergies and medical history before treatment. The service had arrangements for the safe storage, administration, recording and disposal of medicines, including controlled drugs, which were managed by appropriately trained staff.

Data provided by the service through the National Endoscopy Database (NED) demonstrated that sedation practice, including doses of midazolam, fentanyl and pethidine, was routinely monitored. Clinical lead review recorded the NED outcomes as satisfactory.

Mandatory training data provided by the service showed 100% compliance with medication safety training in August 2026.