The Royal Bournemouth 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 safety was a priority for everyone, and leaders embedded a culture of openness and collaboration. We checked 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.

This is the first assessment for this service. This key question has been rated requires improvement. The service was in breach of legal regulation in relation to safe care and treatment.

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. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. We found evidence which demonstrated a commitment to staff development and a supportive learning culture. Feedback from staff was consistently positive about the supportive environment in which they worked, where students benefitted from structured learning, mentorship, and practical experience. We observed this on surgical wards, where student nurses managed patient care within a 6-bedded bay, prioritising needs under mentor supervision. Ward Managers told us they encouraged professional growth. Theatre staff told us healthcare assistants were regularly supported to train as assistant theatre practitioners and operating department practitioners through funded apprenticeships.

Incident reporting was well-understood, with Local Event Reporting Network (LERN) updates readily available, demonstrating transparency and learning from near misses and incidents. Incident reporting was managed through policies, with investigations conducted for serious incidents, including never events, and action plans developed to prevent reoccurrence. The Trust used incident prioritisation reviews to identify trends, and implemented targeted improvement plans to address these. Formalised processes, such as staff meetings, supernumerary periods for new starters, and after-action reviews, ensured good information sharing and collaborative decision making. The positive feedback surrounding the Patient Safety Incident Response Framework (PSIRF) process, with its ‘no blame’ approach and individualised support, further reinforced a culture of learning and improvement. PSIRF is an NHS initiative whereby incident management focuses on contributary factors, rather than assigning blame. Additionally, ‘You said, we did’ projects and observed staff celebrations indicated a culture that values feedback and recognised staff achievements, fostering a positive and engaged workforce who were open to learning and improvement.

The hospital adhered to national guidelines for ‘Learning from Deaths’, conducting thorough reviews of patient outcomes, particularly in mortality and morbidity cases. This process included case record reviews, engagement with bereaved families, and support for affected staff, with quarterly reports submitted to the Trust board. Recent mortality and morbidity meetings highlighted a focus on learning from specific cases, identifying areas of good practice (for example, communication with families) and areas requiring improvement (for example, discharge planning delays). The Trust shared learning from incidents through various channels, such as patient safety and governance updates, posters, and intranet resources. These included topics such as anti-microbial stewardship, oxygen transport safety, and the implementation of Martha’s Rule. Martha’s Rule is a patient safety initiative whereby families can seek a second medical opinion if they feel their concerns have not been heard.

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.

Patient flow and discharge were effectively managed through well-defined pathways. Despite this, the hospital pro-actively addressed discharge needs with a dedicated surgical discharge co-ordinator and nursing team who supported ward staff with arranging care packages, hospital transport, and community referrals.

The handover of care was generally thorough. This was particularly true in the operating rooms, where staff carefully checked patient identification and did safety checks before surgery. The hospital also maintained specific pathways for the management of certain patient groups. For example, trauma patients would be transferred to Poole Hospital. This process indicated Poole Hospital had to accept the patient, and the transfer had to happen within 4 hours. Before the transfer, staff had to do a full check of the patient, including how much pain they were in and how to ensure their safety during the transfer.

Pre-operative care, notably for hip replacements, included thorough assessments and occupational therapy input to optimise patient readiness for going home. Following discharge, patients received detailed information booklets.

The Trust’s transfer policy to other NHS hospitals categorised transfers by complexity, outlining specific escort and documentation requirements. For acutely unwell patients, the 24/7 critical care outreach team enhanced ward-based care. Bed capacity was managed through an outlier policy and ensured appropriate ward placement with clear exception and repatriation criteria. Defined emergency gynaecology pathways with referral and review processes were also in place. All Trust pathways were underpinned by the national 'Getting It Right First Time' (GIRFT) initiative and supported by communication channels like care traffic control and the clinical site team, collectively promoting patient safety and efficient care transitions. GIRFT is a national NHS England program where doctors analyse how different hospitals treat patients, aiming to identify and share the most effective practices. By using data to understand variations in care, GIRFT helps hospitals to adopt best practices, ensuring patients receive high-quality and consistent treatment, while also promoting efficiency within the NHS.

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 prioritised safeguarding adults and children through policies that aligned with statutory requirements and national guidelines. Their safeguarding policy emphasised how safeguarding is everyone’s responsibility, promoting a person-centred approach and the ‘Think Family’ concept. For example, the policy adhered to the Care Act (2014) and the Mental Capacity Act (Amendment, 2019), ensuring decisions are made with the individual’s best interests in mind and with the least restrictive options. To manage challenging behaviours, the restriction and restraint (physical and chemical) adult care policy outlined protocols, including de-escalation and restraint as a last resort, with recording in the Trust’s LERN system. Enhanced care observations were implemented for patients at risk of deterioration or harm, with a policy that ensured these interventions were conducted with respect for patient rights and within legal frameworks.

Feedback from staff of all levels indicated they had clear knowledge around what safeguarding was, and who to report their concerns to. Data from the Trust’s referrals to local authorities, showed 19 adult safeguarding cause for concern forms had been submitted between November 2024 and January 2025. Additionally, 39 children’s safeguarding forms were completed within the surgical directorate during the same period, with 37 originating from the Ophthalmology Department due to ‘not brought’ concerns. A ‘not brought’ concern refers to a situation were a child, or vulnerable adult fails to attend a scheduled appointment.

Training compliance within the surgical care group showed 96.48% completion for registered staff in adult safeguarding, and 81.24% for Oliver McGowan training. Oliver McGowan training is a specific program focusing on Learning Disability and Autism and is a mandatory requirement for all health and social care staff in England.

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.

The service involved both patients and staff in managing risks through a range of policies and procedures. The deterioration and escalation policy outlined how staff, as well as relatives and carers, could escalate concerns about a patient's worsening condition, aiming for early detection and intervention. For instance, this policy mandated the use of the National Early Warning Score 2 (NEWS2) for adult patients. This is a standardised system incorporating vital signs like pulse, blood pressure, and temperature to ensure consistent responses to deterioration. Similarly, the sepsis management framework emphasised the importance of early identification and treatment to reduce mortality, advocating for senior clinician involvement when sepsis was suspected. The service carried out some compliance audits, for example, antibiotic prescribing and the surgical safety checklist, to ensure safe practices were consistently followed. A June 2024 audit showed 100% of patients received antibiotics within the critical first hour of suspected sepsis. The checks on the surgical safety list showed key steps like the ‘Time out’ were always followed. However, completion of the ‘Sign out’ and ‘Debrief’ parts needed to be better. Due to this, the service started using a standard form for the ‘Debrief.’ When the assessment team watched in the operating rooms, they saw the whole surgery team using the checklist and doing the ‘Time out’ properly.

Following 2 never events (in the NHS these are defined as largely preventable incidents that should not occur if safety processes are followed), the service implemented team support initiatives, conducted thorough process reviews, and provided human factors training. To enhance staff communication and gather feedback, the Trust facilitated daily team huddles and collected qualitative data through peer observations, fostering a culture of continuous improvement and a focus on patient safety.

The service did not always detect and control potential risks in the care environment. Staff did not make sure that equipment, facilities and technology supported the delivery of safe care. Overall, we noted inconsistencies in environmental safety, particularly concerning fire safety, and the timely availability of emergency equipment.

For instance, one surgical ward presented multiple environmental hazards such as cluttered corridors and a blocked fire exit. There was also a water leak near electrical equipment and unsecured Control of Substances Hazardous to Health (COSHH) products, raising concerns about unauthorised access to hazardous materials. Fire safety was compromised across several surgical areas due to open fire doors and escape routes obstructed by equipment. We raised this during our assessment and the issues were immediately addressed. A faulty and taped-together curtain track over patient beds was also found posing a safety concern to patients. We highlighted this to leaders and this was promptly rectified.

A widespread concern involved the inconsistent availability of suction canisters and oxygen flow meters in acute surgical bedspaces, with staff relying on the crash trolley (a portable wheeled cabinet containing essential medical equipment and medications used to treat life-threatening emergencies, particularly during cardiac arrest or respiratory distress) to obtain this equipment in an emergency. It was unclear whether suction and oxygen would be available if simultaneous emergencies occurred. The Trust said the need for an oxygen flow meter and suction cannister in a bedspace would be based on a dynamic risk assessment to identify clinical need. While leaders cited ‘clinical need’ for this setup, no dynamic risk assessments demonstrating an evaluation of individual patient clinical needs were found in patient records.

As a result of this concern, we requested to see what risk assessments were in place to mitigate this risk. The received assessment provided following the inspection was dated on the day which the inspection occurred. This raised further questions about prior assessments and leadership awareness.

Additionally, a review of the service’s incident reports showed near misses relating to equipment not always being available. For example, a lack of timely replacement of emergency equipment for the resuscitation trolley, such as oxygen cannisters. A report from September 2023, detailed a 1.5-hour delay in replacing an empty oxygen tank on the resuscitation trolley. This highlighted the need for a timely replacement process when the emergency trolley serves as the primary mitigation.

Similarly, another incident involved an acutely unwell patient requiring suctioning. Staff discovered the suction unit on the crash trolley was not functional during the incident due to a missing piece. We also noted the practice of sharing crash trolleys between 2 acute surgical areas (Surgical Assessment Unit and Ward 17) which presented a potential risk with equipment availability during concurrent emergencies.

On Ward 17, we found unsecured scalpels, needles, and easily accessible COSHH keys and scissors, issues that were immediately addressed upon escalation. Obstructed crash trolleys, often surrounded by equipment such as observation machines and bladder scanners, further hindered timely access to emergency equipment.

In November 2024, a fire risk assessment of main theatres revealed significant storage problems, leading to obstructed fire escape routes and combustible items stored near potential ignition sources. These were still an ongoing concern despite being raised as part of a fire risk assessment in November 2024. Fire warden training compliance was also low Trust-wide, with only 40% having up-to-date training, contrasting with the 95% compliance for mandatory fire training. Electrical safety, governed by a policy and Standard Operating Procedure (SOP) for portable appliance testing, aimed to prevent electrical accidents, but the observed clutter and unsecured electrical equipment indicated potential risks.

The service did not always make sure there were enough qualified, skilled and experienced staff.

Staffing levels across the surgical division presented ongoing challenges. It is recognised that nationally there is a shortage of medical and nursing staff posing a challenge, which was impacting on the services’ ability to recruit sufficient staff. The Trust had a policy in place for raising red flags and implementing a critical staffing protocol. This outlined procedures for managing and governing safer staffing levels, particularly during periods of high pressure. Despite this being in place and followed, this did not always mean the ward would have the required cover. The Trust's electronic staffing platform, which monitored real-time staffing against patient acuity and dependency, indicated a staffing deficit that did not always meet patients' needs, a sentiment echoed in most of the surgical areas we visited. Staff feedback indicated staffing numbers rarely aligned with patient demands. However, we observed that staffing levels were reviewed at daily huddles to ensure safe staffing across the surgical wards. However, surgical wards faced frequent staffing shortages, reportedly leading to delays in medicine administration and patient discharges.

Managers across surgical areas indicated they were regularly pulled from their managerial duties to cover staffing gaps, and band 6 nurses reported consistently working overtime. Staff told us they felt existing staffing templates failed to adequately address patient needs, particularly in wards operating with unfunded additional beds, and recommendations for revised templates had not been addressed by senior leadership. However, following review of January 2025 board papers, we saw evidence that ward staffing templates had been reviewed and uplifted.

Similarly, a surgical ward reported staffing levels below planned numbers. Orthopaedic theatres faced difficulties when workload exceeded established templates, with reported vacancies for both registered nurses and healthcare support workers. The orthopaedic ward electronic information board corroborated this, consistently showing lower actual staffing compared to planned levels.

In orthopaedic theatres, staff told us they frequently experienced fluctuating staffing levels, often relying on supernumerary staff to maintain safe levels for operations. A surgical ward designed for 24 patients but accommodating 28 at the time of assessment, routinely functioned with 5 registered nurses and 2 healthcare support workers; 21 of these patients were classified as high dependency, requiring a higher nurse-to-patient ratio.

Despite these staffing challenges, staff demonstrated strong teamwork and a clear dedication to their roles and flexibility to cover where this was needed most.

To support newly qualified staff, the Trust offered a nationally accredited preceptorship program. New starters had to attend this program for their first 2 years. It provided structured support, including regular meetings with mentors, continuous learning opportunities, and well-being support.

Appraisal compliance rates within the surgical directorate showed a positive trend of improvement over time. For nursing staff, compliance varied from a low of 32.9% in June 2024 to a high of 76.8% in January 2025. Healthcare support worker appraisal compliance followed a similar pattern, ranging from 28.8% in June 2024 to 79.6% in January 2025. Medical staff, demonstrated higher and more consistent appraisal completion rates, fluctuating between 73.2% and 89.2%. The surgical directorate experienced a staff turnover rate of 8.24%.

The service did not always assess or manage the risk of infection. Staff did not always detect and control the risk of it spreading.

While the Trust had Infection Prevention and Control (IPC) policies aligned with national guidelines, our observations revealed inconsistencies in practice. There was a need for more consistent adherence to policies to ensure patient safety and prevent healthcare associated Infections.

Theatre environments generally maintained high hygiene standards,staff were observed demonstrating hand hygiene compliance and using Personal Protective Equipment (PPE).

Surgical Departments demonstrated good cleanliness, achieving over 95% on internal cleaning audits between January 2024 and January 2025. However, staff feedback indicated delays in patient surgeries due to contaminated sterile trays, although we did not see any evidence of this during our inspection.

During our observation, we noted several specific infection control issues. For instance, a theatre support worker did not follow national guidelines for proper mask removal. Additionally, some computer screens in the operating room had a sticky residue, and a staff member was seen with inadequate eye protection during a surgical procedure. We observed some of the waterproof covers on stools were ripped, and on a surgical ward, part of the sluice floor was worn. We pointed these issues out when we were there, and leaders told us they would rectify them. However, in all sluice rooms we visited, commodes appeared clean, and there was consistent use of ‘I am clean’ stickers. We observed good hand hygiene, and we saw staff regularly cleaning equipment in-between patient use.

Throughout all the surgical areas we visited, including the wards, anaesthetic rooms, and recovery areas, we consistently observed paper stuck to walls, doors, and cupboards using tape. This included posters and important staff information. Because the paper was not protected with a laminate, it could not be cleaned properly. The widespread use of unprotected paper created a risk of spreading infections.

Despite these inconsistencies, regular IPC oversight occurred through auditing processes, and daily staffing meetings. For example, in the last audit period, staff looked at intravenous (IV) sites and achieved 94.6% compliance. This check, called a Visual Infusion Phlebitis (VIP) score, means staff look at where the IV line goes into the patient to make sure there are no visible signs of infection. This suggested oversight in this area and processes were generally effective.

Notably, the Royal Bournemouth Hospital (RBH) reported a low surgical site infection rate of 0.4% for hip replacements, below the national average of 0.7%.

The service did not always make sure that medicines storage was safe and met people’s needs, capacities and preferences.

Trust policies mandated secure storage, such as locked cupboards for all medicines. However, on a number of surgical wards we observed unsecured Sodium Chloride ampules and 2 unlocked cupboards containing fluids for intravenous infusions, along with accessible antibiotics on a treatment room shelf. This created opportunity for medicine errors, the potential for contamination, and easy access, particularly by vulnerable or confused patients.

Diabetic patients who were able to manage their own medicine could do so with specialist oversight. This adhered to national guidelines outlined in their Self Administration Policy of Insulin for Adult Inpatients. However, the Trust acknowledged the absence of a specific policy for the self-administration of other medicines. This could lead to missed opportunities for patients to take on a more active role in their care, potentially hindering their independence and making the transition home more challenging.

We found some medicines that were past their use-by date. For instance, on a surgical ward we found 3 bags of expired fluids. In the operating rooms, some Potassium fluids were out-of-date, having expired in December 2024. We also found expired equipment on the trolley used for difficult breathing situations. This included a tracheal tube introducer that expired in April 2023 and a tracheal intubation stylet that expired in August 2023.

Furthermore, staff demonstrated a lack of clarity regarding the storage and reconstitution of Dantrolene, an emergency medication for malignant hyperthermia (a rare disorder in response to certain anaesthetic medicines) stored in theatres, with uncertainty about the location of the necessary water for reconstitution. Additionally, we found 2 unsecured oxygen cylinders on the floor in the Ward Clerk’s office on an orthopaedic ward. While no patients were found to have been harmed as a direct result of these issues, increased vigilance and consistently applied safe practices were crucial to prevent potential future harm.

Some audits demonstrated some positive outcomes, including refrigerator temperature checks across surgical areas and Controlled Drug (CD) audits in 8 wards, revealing 100% compliance with locked CD cabinets and the consistent separate storage of patients' own CDs.