Poole 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 requires improvement. At this assessment, the rating has changed to good. This meant people were safe and protected from avoidable harm.

This service scored 66 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Trust policies and procedures gave staff guidance about reporting, managing, investigating, and learning from incidents. The trust's incident reporting and management policy was published on their website and met the requirements of the National Patient Safety Incident Response Framework. The Patient Safety Incident Response Framework (PSIRF) is focused on learning from incidents to provide safer care to patients. Following the requirements of the PSIRF, the trust had also published their Patient Incident Response Plan on their website. Following their analysis of reported incidents, the trust had identified patient safety priorities for the next 12 to 18 months and detailed how they would respond to the priorities. This included responding and making improvements in relation to patient falls, venous thromboembolism prophylactic medicine (medicine given to reduce the risk of patients developing a blood clot (VTE) in their veins), pressure ulcers, deteriorating patient and mental health. Information provided by the surgical service, which included minutes from meetings and discussions with staff demonstrated the surgical service was aware of the priorities, kept them under review and actions were taken to make improvements.

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Review of incident investigation reports provided by the service showed areas for learning and improvement were identified and action plans were developed. Action plans had clear timescales for completion of actions with a designated responsible person or group. From the investigation reports it was evident duty of candour was considered. Duty of Candour is legislation that requires healthcare providers to be open and honest with patients when things go wrong with their care and treatment. Duty of Candour letters to patients and/or their families gave apologies, findings from investigations were shared with the patient and/or families and the service offered to discuss the findings with the patients and/or family.

Staff we spoke with had an understanding of the patient safety incident response framework. They knew what incidents they needed to report and how to report them. Multiple processes were used to share learning from incidents with staff. This included staff huddles, team meetings, emails, and newsletters.

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Morbidity and Mortality meetings were used to identify any learning from patient outcomes. The trust's Learning from Deaths (Mortality Review) Policy gave guidance about what deaths must be reviewed, about the management of morbidity and mortality meetings including who should attend, frequency of meetings, and what the outputs of the meeting should be, for example learning for clinical practice. Review of morbidity and mortality meeting records provided by the service showed learning from deaths was considered and action plans developed to improve practice were put in place when assessed as needed.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. Staff made sure there was continuity of care, including when people moved between different services.

The trust discharge policy and processes gave staff guidance about managing patient discharges safely. Documentation provided by the service demonstrated the service worked with system partners to support discharge of patients. During our onsite visit, observations showed that plans and progress for patient discharges were discussed by the multidisciplinary staff teams (medical staff, nursing staff, therapists, and discharge coordinators) at board rounds. Discussion with discharge coordinators showed they liaised with external agencies, such as social care providers, voluntary services, and mental health care services to ensure patients received continuity of care when discharged. Prior to the assessment, CQC had received some information from patients, their relatives and other health and social care providers. However, some of this information indicated that for a small number of patients there was sometimes a lack of information about patients' care and treatment provided and a view that some patients were not well enough to be discharged.

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Surgical services were arranged across 2 of the trust hospitals, Poole Hospital and Royal Bournemouth Hospital. In some circumstances, patients had to be transferred between the hospitals to access the treatment they needed. There was clear guidance in place to support staff to do that in a safe and timely manner.

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At times, due to bed pressures, surgical patients were accommodated in wards that were not specific to their surgical needs. These patients were described as `surgical outliers.' There were processes in place to ensure patients accommodated as a `surgical outlier' were reviewed by their relevant surgical medical team. Patients who were `surgical outliers' that we had conversations with said they were seen by their relevant surgical medical team. Staff confirmed `surgical outliers' were reviewed daily by the relevant surgical medical team. This supported continuity of the treatment plan for patients.

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The service treated large numbers of patients who had sustained a fractured neck of femur. There was a pathway in place that followed patients through their treatment and recovery. This pathway had supported improved performance for patients with a fractured neck of femur, meaning they received surgery for their fractured neck of femur in a timely manner. The improved performance meant there was a reduced risk of patients being exposed to avoidable harms as delays in surgery for fractured neck of femur are associated with poor outcomes for people. However, the pathway did result in patients being moved to different wards dependant on what stage of the pathway they were on. Multiple bed or ward moves for patients has the potential for patients to have a poor experience and increase the risk of disorientation and confusion. However, patients we spoke with did not express any concerns about bed or ward moves and patient and /or relatives who contacted CQC did not raise any concerns about bed or ward moves.

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The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff 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 trust had a safeguarding policy that referenced relevant national guidance. It provided clear guidance about the actions staff needed to take if they were concerned a patient had been subject to abuse and clear guidance about action staff needed to take in the event of an allegation of abuse. The service provided evidence they referred safeguarding concerns to the local authority or in the case of domestic abuse to the domestic abuse referral place.

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Policies were also in place to guide staff about the use of restraint and restriction to ensure they were not used inappropriately. This included the legal frameworks for restraint, who could or could not carry out restraint, and the training requirements for people who could carry out restraint. Our review of the records from the last 3 restraint events demonstrated that least restrictive practices were considered and acted on before restraint was used.

Staff received training about safeguarding. All staff groups, except for medical staff, met the trust target of 90% compliance with safeguarding training. Medical staff compliance with safeguarding training ranged from 77% - 89% (June - Dec 2024).

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The service did not provide details about what level of safeguarding training staff completed. However, their safeguarding policy detailed the training was aligned to national guidance. This included Essential Core Skills, Safeguarding Children and Young People: roles and competency of healthcare staff, 2020 and the Adult Safeguarding: roles and competencies for healthcare staff 2018. The policy was approved in September 2024 and was due for review in June 2027. However, the Adult Safeguarding: roles and competency for health care staff 2018 had been superseded by a revised document published in July 2024. This meant it could not be fully assured staff training was in line with current national guidance. However, by not following the changes in the national guidance would have minimal impact on the skills and knowledge of staff. Staff we spoke with had a good understanding about safeguarding, and knew the actions they needed to take in the event they suspected a patient may have experience abuse or be exposed to abuse. Staff knew how to contact the safeguarding leads in the trust for advice and guidance.

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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.

Staff had access to policies and procedures to support them with assessing risk of harm and deterioration of patient's conditions. The deteriorating and escalation policy gave staff guidance about how to monitor for and manage a deteriorating patient. This referenced national guidance and gave guidance about actions in response to NEWS2 (national early warning score) scoring, support from the critical care outreach team, and treatment escalation plans. Treatment escalation plans are tools used by staff to record and communicate patients personalised and realistic goals for treatment, particularly when their condition may deteriorate. The Sepsis Management Framework referenced the national Sepsis 6 Pathways and gave staff clear guidance about what actions to take in the event of suspected sepsis. The service provided audits of compliance with the sepsis pathway for the emergency department. However, the service's submission for sepsis audits detailed there were no audits relevant to surgical patients. This meant the service did not have oversight of the management of suspected sepsis in the surgical services could not be assured staff safely managed suspected sepsis.

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Staff used a nationally recognised tool to identify deteriorating patients and escalated them appropriately. The National Early Warning Score (NEWS2) was used in the service to identify patients at risk of deterioration. Staff completed scores correctly. When a concerning score was calculated the patient was escalated for medical review. The service monitored compliance with the NEWS2 process. Information provided by the service showed they monitored whether a full set of observations were taken and whether they were taken on time. However, there was no detail about whether the correct actions were taken in response to the NEWS2 score, whether patients scores were escalated as per guidance. This meant the service could not assure themselves staff took the right actions when required to manage risks to individual patients' health.

Systems were in place for patients and their families, friends, or carers to escalate concerns about their conditions. Call 4 concern enabled patients and their friends, family, or carers to contact the critical outreach team if they felt their condition was getting worse and was not being addressed by the staff on the ward. Posters advertising this service were visible on the wards and there was information about this process on the trust website.

Staff completed risk assessments for each patient on admission using nationally recognised tools. This included a range of risk assessments, for example, falls, pressure areas, sepsis, nutrition, and venous thromboembolism (VTE). When actions or plans were required to reduce the level of risk, patient records showed these had been completed.

Pre-operative assessment processes included online health questionnaires. Health conditions that might affect surgery were identified through the questionnaire, which allowed them to be addressed prior to surgery. This included face to face consultations where individual plans were discussed to make surgery as safe as possible.

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The service used the nationally recognised World Health Organisation (WHO) 5 safe steps to surgery check list. This is a checklist developed with the aim to decrease errors and adverse events and improve safety and outcomes for patients undergoing surgical procedures. Audits of compliance with the WHO safety checklist showed good compliance, but the service identified improvements were needed in the debrief part of the check list. Observation of practices during the site visit showed use of the WHO safety check list was embedded into practice, with staff fully interactive and focussed with the process.

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

Staff did not ensure all equipment was safe to use. We identified some concerns with some equipment in theatres. We identified 4 pieces of critical equipment where the next service date indicated they were beyond their service date. This included 3 diathermy machines (diathermy is a medical technique that uses heat generated by an electric current to cut or coagulate tissue, often used in surgery) and an oesophageal doppler monitor that monitors cardiac function and guides fluid and medicine administration during surgery. The Trust Medical Devices Management policy detailed, “At each technical service event, a label indicating the date of the next due event will be attached to the equipment. Inspection of this label should form part of the device’s routine pre-use checks. It is the responsibility of the individual user to check device is in date prior to use.” There was no evidence that staff had identified these 4 pieces of equipment were past their service date as they were still in use. This presented a potential risk that staff were using equipment that was unsafe to use.

We identified some out of date consumable equipment. There were out of date oxygen catheters on a difficult airway trolley. There was a specific intubation tube that had an expiry date of 1 October 2024 and a label that detailed, ‘no replacement’. A member of staff said this piece of equipment would be used if needed and they had used out of date stock in the past. The member of staff indicated in conversation this piece of equipment was preferred by a specific member of the anaesthetist staff team. The out of date consumable equipment posed a potential risk of harm to patients because it could not be assured the equipment was safe to use. All identified out of date consumable equipment was removed and where possible replaced during the inspection.

Staff in theatres said there was an issue with sterile services and availability of sterile instrument packs that were safe to use. Sometimes the sterile kits had drapes with holes and dirty instruments in them. To mitigate this risk, they always opened the kit and checked all equipment to ensure it was fit for use before anaesthetising the patients. Staff said they sometimes had to borrow surgical equipment and kits from Royal Bournemouth Hospital. Staff said all incidents of unclean kits were reported as a safety incident and that it was detailed on the risk register. However, we saw no evidence of unclean sterile surgical kits during the inspection activity.

Leaders described a risk that not all theatres had an uninterruptible power supply. They described actions that were taken to reduce this risk, and the business cases in progress to acquire uninterruptible power supply for all theatres.

The trust and the surgical service recognised that patients admitted for surgical procedures who also had mental health conditions were sometimes at risk of self-harm. The trust had developed a process for assessing the environment for ligature risks. However, it was unclear whether this had been embedded into practice as no examples of completed ligature risk assessments were provided.

There was lack of evidence the service monitored or audited the environment. We asked the service for environmental audits. The service provided the Patient Led Assessment of the Care Environment (PLACE) results for 2023. PLACE assessments involve local people (known as patient assessors) going into hospitals as part of teams to assess how the environment supports the provision of clinical care, assessing such things as privacy and dignity, food, cleanliness and general building maintenance and, more recently, the extent to which the environment is able to support the care of those with dementia or with a disability. The results were trust wide and not specific to surgical areas.

There was lack of evidence the service assessed any risk associated with the environment. We requested a sample of risk assessments from the ward and theatre environments. We were only provided with a health and safety observational risk assessment where the date of completion was during our inspection. This was completed after we raised concerns about the environment in one of the medical staff offices.

Leaders said that the process of ‘matron walkabout’s included review of the environment. ‘Matron walkabouts’ had commenced in September 2024.These looked at areas of the patient care including the environment. Evidence we reviewed demonstrated a responsible person was allocated for improvement actions and date for next assessment was also included.

Staff completed daily safety checks on all specialist equipment including the resuscitation equipment and records of this were completed. However, for some records we identified some gaps. For example, for the period 9 December 2024 to 29 January 2025 there were 5 dates when there was no record that an anaesthetic machine was checked.

However, ward environments were generally tidy and free from ‘clutter.’ Bedsides had appropriate equipment including oxygen and suction equipment.

Electrical equipment in each ward area had been safety checked and maintained so was safe to use. Most equipment had a sticker attached which detailed when it was next due for servicing.

The service did not always make sure there were enough qualified, skilled and experienced staff. However, staff received effective support and development. Staff worked together well to provide safe care that met people’s individual needs.

There were mixed views from staff about whether their areas were well staffed. Staff in some areas commented they had sufficient staff, but others described they experienced challenges with ensuring safe staffing. It is recognised that nationally there is a shortage of medical and nursing staff which was impacting on the services’ ability to recruit sufficient staff.

There were shortfalls in the maxillofacial consultant numbers. Staff said the service should have 6 maxillofacial consultants but only had 3. Some staff spoke about a shortage of junior doctors to cover the general trauma night shift rota. However, staff did not give any examples of how this impacted the safety of the service.

The orthogeriatric medical team explained their service provision had reduced since one of their team members left. They explained they could now only do 4 ward rounds per week and said that greater orthogeriatric input would have prevented patient deterioration, although they did not provide examples. Other medical staff spoke about challenges in getting geriatric support for patients because of the lack of orthogeriatric medical staff.

Staff and patients spoke about the impact of not having housekeepers on the wards. One ward had no housekeeper at weekends and 1 ward had had no housekeeper on the ward for 4 weeks due to sickness. This meant nursing staff had to fulfil housekeeping duties which reduced the time they had to care for patients. For the ward that did not have a housekeeper at weekend, patients said they did not get many warm drinks at weekends.

The Trust used a nationally validated safe staffing tool to determine nurse staffing requirements on wards. However, staff on one ward said the safe staffing tool used did not accurately reflect the acuity of patients on their ward and did not accurately calculate how many staff were required.

Planned and actual staffing numbers were displayed on wards. It was observed that not all wards met their planned staffing numbers. Staff said that often staff were moved to other wards to lessen risk of insufficient staffing, and it was common practice that band 6 and 7 nurses had to work clinically on their management days to cover gaps in the rota. This meant either they had to work extra hours to complete their management work, or some management work did not happen, such as completing audits.

The service used agency and bank staff to lessen risks of staff shortages. The top reason for use of agency and bank staff was due to staff vacancies, staff sickness both short term and long term, enhanced care needs, and extra capacity/ escalation being the other reasons for use of agency and bank staff.

However, there were other areas that described they had no concerns about their staffing levels.

Observation of a daily staffing huddle showed that actions to mitigate risks of low numbers of staff was to use supernumerary staff and take staff of management days to do clinical work. One of the main pressure points was lack of provision of agency mental health nurses and care workers to support patients with mental health needs during the night. There was evidence of staff mutually helping each other across the wards. However, this reflected what staff said that if they were staffed to template or above, staff were frequently moved to support other wards.

Staff confirmed they received training and appraisals. All staff completed mandatory training appropriate to their roles. The trust set a target of 90% of staff to complete mandatory training. Data provided by the service showed, that for surgical services across both Poole Hospital and Royal Bournemouth Hospital, that between January 2024 and December 2024 only nursing and healthcare support workers consistently met that target. Administration and clerical staff compliance for the same period ranged from 87% to 92% and medical staff performed the worst with compliance ranging between 77% to 83%. Staff spoke positively about the opportunities they had for career development.

Data provided by the service showed that in the 12 months preceding the assessment, the number of staff receiving an annual appraisal had increased. Data provided by the service showed that over the surgical care division (both Royal Bournemouth Hospital and Poole Hospital) appraisals rates had improved. For medical staff there had been an improvement from 78% to 80% receiving an annual appraisal. For nursing staff, the figure had increased from 65% to 88%. Healthcare support workers had increased from 60% to 89% of staff receiving an annual appraisal, and for administration staff there was an improvement from 43% to 65%. However, there was still room for further improvement.

The service assessed and managed the risk of infection. Staff mostly detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Most areas were visibly clean and had suitable furnishings which were visibly clean. Cleaning staff were visible in all areas. Observation showed staff washed their hands between patient interactions, cleaned equipment between patients use and wore clothing that ensured they were bare below the elbows. Equipment on the wards had `I am clean' stickers on them, which detailed the date and time they were last cleaned.

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However, we observed some equipment in theatres, such as trolleys and bins that had dust on them. Governance meeting records showed the service had identified that in some areas medical staff did not always comply with best practice and policy. Some did not always remove gloves between patient interactions. To support improvements, staff were encouraged to challenge any members of staff who did not comply with removing gloves between patient interactions.

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Staff had access to personal protective equipment as required for the areas they worked in. We observed staff mostly used personal protective equipment appropriately. In theatres staff wore approved personal protective equipment which included theatre scrubs, CE marked footwear, hats, masks, and sterile gloves and gowns as per policy. Where laminar airflow was available, surgical equipment was set up under the laminar airflow hood. Laminar airflow is a system that provides continuous air flow that is smooth and uniform in one direction. It is used in theatre environments to reduce the risk of surgical site infections. However, some theatre staff continued to wear theatre hats outside the theatre environment. This was not in line with hospital policy and national guidance (The Association for Perioperative Practice Infection Control 2024 and NICE Quality Standard 49). It was noted from review of governance meeting records the service was taking action to improve staff compliance with this.

The service monitored staff compliance with health care practices that posed risk to patients of health associated infections, such as presence of urinary catheter, presence of intravenous device, pulmonary supports such as ventilation and surgical procedures. Results of monthly audits for November, December 2024 and January 2025 showed that most wards and surgical areas were between 90% and 100% complaint with the relevant trust procedures in relation to these points.

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The service monitored compliance against NICE 125 Surgical site infections: prevention and treatment. However, this was last completed in 2020 during which time the service was assessed as compliant with the national guidance. Surgical site infections were monitored. Data provided by the surgical service showed low rates of surgical site infections for fractured neck of femur surgery. Between October 2023 and December 2024, less than 1% of patients experienced a surgical site infection, with none experiencing surgical site infection between October 2023 and April 2024. However, the service did not provide data for surgical site infections for other types of surgery carried out at Poole Hospital.

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Hand hygiene audits monitored staff compliance with national guidance and trust policy about handwashing. For January 2025, the audit showed 96% compliance across surgical services both at Royal Bournemouth Hospital and Poole Hospital. There were 2 wards who scored below 90%. However, we did not identify whether this was a theme for these wards or one off occurrence of low compliance, as the service only provided the data for January 2025.

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The service, due to a lack of oversight, did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. However, patients had a good understanding about the medicines they were receiving.

Policies gave staff guidance about how to safely manage medicines. The trust had separated medicine management policies into 8 different policies after feedback from staff who said all information in one big policy was difficult to navigate and find the information they needed. However, apart from self-administration of insulin, there was no policy to support patients to self-manage and self-administer medicines. This meant there was potential for patients not to have access to some essential medicines, for example for asthma, when needed.

There was lack of information from the service about the monitoring of the safe management of medicines for ward and department areas. We requested medicine audits and associated action plans. We received audits that monitored individual wards or departments compliance with policy about the management of controlled drugs. However, there was no detail about what the target compliance rate was. The service said that in response to these audits, refresher training was in place across surgical wards with the aim of achieving 100% compliance in all areas of controlled drug management.

The service audited compliance with monitoring of refrigerator temperatures. For the surgery division, in January 2025 of the refrigerators audited, 76% were fully compliant and 24% non-compliant, (this included no submission of information for some refrigerators). For those that did not comply with the policy there were none that had missed recording of fridge temperatures for over 4 days. No further information was provided so we could not assess trends of compliance with the policy. There was no audit to identify if staff had taken appropriate action, as detailed in policy, if fridge temperatures were outside the recommended range.

There was no evidence of audit or monitoring of the general management of medicines. This had the potential to risk a lack of oversight and lack of identification of any concerns or issues with the management of medicines.

However, the separate divisions of the surgical services carried out audits relevant to their field of practice. For example, there were audits about the use of tranexamic acid on hip surgery, appropriate use of antibiotics for perineal abscess and audits of analgesia prescription for mild to moderate pain in the acute surgical unit.

Staff completed medicines records accurately and kept them up to date. Records detailed doses prescribed and administered. Staff stored and managed all medicines safely with medicines stored safely in locked cabinets.

Medicines required in the event of emergencies were readily available on wards and in theatres. This included in theatres dantrolene for the treatment of malignant hyperthermia.

Controlled medicines were stored and managed in line with national guidance, staff completed checks on controlled drug stock levels twice a day. Staff checked the temperature of medicine refrigerators twice a day. Although in some areas there were occasional gaps in the recording of refrigerator temperatures, the records and discussion with staff evidenced they followed process to escalate if refrigerator temperatures were outside the required range.

Patients said they understood what medicines they were receiving and that staff provided them with pain relief when they needed it.