St Luke's 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 people were protected from abuse and avoidable harm.

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

This meant people were safe and protected from avoidable harm.

The service was in breach of regulation for premises, environment and equipment.

This service scored 69 (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 did not always have a proactive and positive culture of safety based on openness and honesty. They did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

Staff knew how to report incidents when they occurred. However, we heard that some staff lacked clarity regarding what were reportable safety incidents. The trust demonstrated a range of support available for staff who were unsure regarding incident reporting.

The service had not had any never events in the last year.

Some staff clearly described a process of reviewing and learning from incidents. We heard about shared learning from other areas. However, not all staff felt that they received direct feedback following incidents. Staff survey results for 2024 showed 68% of staff within St Luke’s Hospital reported receiving feedback about changes made in response to reported incidents. Staff were keen to receive feedback.

In outpatient areas daily huddles were used for sharing of patient safety incidents and to raise learning. All clinics that were managed by other clinical service units had governance processes for sharing learning.

Staff understood duty of candour and gave people full explanations when things went wrong.

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.

Appropriate systems were in place to ensure essential information was received at the start of the patient journey. The paediatric outpatients service used an ‘advice and guidance’ system to ensure appropriate bookings for appointments were in place.

There was a central patient booking service in place with clear booking rules and processes for each clinic type. Processes ensured all available appointment slots could be taken up. This system also supported management of patients who ‘did not attend’ (DNA).

The trust kept up to date directories of services to ensure timely and appropriate transfers could be made easily to the correct team.

The team were in the process of setting up a ‘6-4-2 system’ for the outpatient department. This was a system of checking at 6-, 4- and 2-week intervals for any cancelled clinics, any possible cover arrangements and offering out sessions to other clinical teams according to Referral to Treatment (RTT) waiting times and other clinical pressures. This supported optimal use of appointment slots in turn supporting provision of timely and safe care.

We saw collaborative and joined up working with clear pathways of care for people. There were a number of ‘one stop shops’ across outpatient areas allowing people to attend once and have a range of needs met. For example, an early rheumatology assessment clinic offered medical, nursing and therapy input within the same appointment.

Staff involved all the necessary healthcare and social care services to ensure patients had continuity of safe care, both within the service and post-discharge.

Where emergencies arose the outpatient teams would call a dedicated internal phone number for a response alongside calling for an emergency ambulance. All staff were clear this was the process.

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 were trained in safeguarding adults and children to the appropriate levels. The trust targets for safeguarding adults and children training were met.

Staff we spoke with knew how to make a safeguarding alert. There was a Trust wide safeguarding team available for advice. There were safeguarding leads within the departments.

Support information such as for those experiencing domestic violence was displayed in all waiting areas, including in toilets. This was displayed in different languages.

Staff within the paediatric outpatient team gave clear examples of when they would raise safeguarding concerns. Staff understood and followed a clear escalation process. There was a red flag alert system on electronic records for higher risk children.

There were up to date safeguarding policies in place for both adults and children. The adult policy included a QR code to access the NHS safeguarding application. Both policies included appropriate links to other useful websites and necessary referral forms for relevant local authorities.

Staff were aware there was a child abduction policy in place. Mock scenarios were carried out and examples of learning were shared from mock scenarios to ensure there was a clear response system. Relevant adult outpatient staff were clear on their responsibilities in an abduction situation.

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 communicated with patients and ensured they understood their care and treatment.

People were supported to understand risks and how to keep themselves safe.

In adult outpatient areas the trust had a standard operating procedure for Patient Initiated Follow-Up (PIFU). This process allowed people to access support when needed and was a priority identified from the 2022/23 NHS Operating Plan. There was a clear process for identifying which patients would be suitable for PIFU. There were clear criteria for those not suitable, for example, those who could not easily contact the service or who had complex health issues. Shared decision making was key to the process and patients could decline this pathway if they did not feel it met their needs. For those who agreed to follow this pathway, a clear management plan would be drawn up.

In the paediatric outpatient service, staff communicated with patients and families and made sure they understood signs of health deterioration. Staff worked with patients and families or carers to identify actions to take in the event of deterioration. We saw joined up paediatric plans that were red, amber and green (RAG) rated with actions to take at each stage of deterioration.

The child health psychology team worked with children and families within the context of the health needs and supported advocacy for individualised needs where necessary.

In emergencies staff were clear on the procedure to summon help. If an emergency response was required 999 would be called for an ambulance.

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.

Most outpatient services were housed within Horton Wing of the St Luke's Hospital site. Some were also housed in external buildings and longstanding portacabins.

Horton Wing housed the main reception area for the site. From there patients would be redirected to the appropriate buildings or areas within Horton Wing.

The access to Horton Wing was level access and there was signage on entering along with volunteers on hand to support with directions. There were lifts to each floor and level access through departments. The main entrance was also accessible by trolley and wheelchair. The paediatric reception area was on split levels for younger children to see over.

Drinking water was available in each area and staff checked there were cups available at the start of each day.

Bariatric chairs were available in the main adult outpatient area.

Security arrangements did not always support safe care. Staff at the main reception of the site finished their shift at 4pm and a security officer took over. The security officer was based at main reception from 4pm until reception staff returned the following day. The main entrance was locked from 8pm to 7am and CCTV (closed circuit television) cameras monitored the area remotely 24 hours a day. There was only one security officer for the site, therefore, there was no assurance that there was always adequate staff cover at the main reception if there was a security incident in another area of the site. The paediatric area did not have electronic door entry access for security management; however the main reception area faced the entrance and staff consistently went to check who people were when they arrived if they did not sign in.

Not all clinic rooms in adult outpatient areas had staff safety call alarm buttons to enable them to call for help if needed. Staff told us that adjoining rooms had buttons to sound the alarm but this did not support safety when incidents occurred in a room without an alarm button. We heard an example where a patient had collapsed and the staff member had to shout for assistance. We also reviewed a risk assessment that identified the layout of rooms posed an increased risk to physical and psychological safety of staff. We saw the risk assessment had been carried out in July 2025. We saw actions identified to explore alternative safety measures. However, we did not see any immediate action to mitigate risks. There was an expected date of October 2025 for completion of exploration into alternatives. On the risk assessment from July 2025 there appeared to be a residual risk score identified. This score should reflect the risk once all mitigations are actioned and adequate control measures in place. However, the mitigations recorded were explorations into alternatives rather than definite actions that had taken place to mitigate risks.

Resuscitation trolleys for adults and children were in situ and checked regularly. We saw that a resuscitation trolley had been used prior to inspection and there had been a short delay in replenishing items as the replenishment resuscitation equipment was at Bradford Royal Infirmary site. Although, there was at least one of each item required remaining on the trolley.

There were also portable Automated External Defibrillator (AED) devices in each area.

All equipment reviewed during the inspection was clean and most equipment was checked within date. However, we found one set of scales that was not checked within date. We raised this during inspection and were advised that a check of all equipment would be carried out.

We reviewed fire risk assessments. We saw one risk assessment for D Block identified significant findings. This review was first completed in March 2022 and again in November 2024. The risk rating was deemed as high with recommendations for immediate interim controls and action to address significant findings. It was not clear what differences had been found between 2022 and 2024 and whether any actions had been taken since 2022 to action the significant findings. We saw there was a backlog of estates maintenance work.

An outdoor space was accessible with some play equipment for children and seating areas. However, one set of tables and chairs was noted to be old and rusted. The trust informed us following inspection that this equipment had been removed.

The paediatric area was decorated with child friendly pictures, although this was aimed at younger children rather than teenagers. There was a play area for younger children and a play specialist available to engage children in activities.

We observed the waiting area in paediatrics to get loud and busy after 3.30pm. Staff told us and we saw there was not enough space in the department for a quieter area to support, for example, children with autism. Some children were able to sit in the departments corridors to wait for appointments if there was seating available. Staff told us the number of children needing appointments had increased but there was not always enough consulting rooms available to manage the increased demand. The environment had not been adapted to meet the changing needs of the service.

A quiet room had been identified within the adult outpatient area for people needing quiet space, for example, people who had received bad news. However, at the time of inspection this room also housed a chair that was out of use due to cracks in the wipeable cover and was not set up as an inviting space. We saw the table in the room was cluttered with unused pharmacy bags.

CCTV was installed in response to two incidents relating to hostility towards staff. Monitors showing a live view of the camera were also installed, making people actively aware they were being recorded on CCTV to support deterrence of inappropriate behaviour. CCTV signage was present at hospital entry points including parking pay and display areas, however, was not always visible within departments.

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.

Clinics were reviewed a week in advance. Rotas could be planned accordingly to ensure all areas were covered. Managers calculated the number and grade of nurses and healthcare assistants required. Paediatric services had access to registered children’s nurses.

There was not always enough staff to match staffing establishment on all shifts within adult outpatient areas. This was often due to sickness. There was recognised high sickness rates in adult outpatients. The reason for the high sickness was understood and leaders made adjustments to work allocation as far as possible to support staff. A strategic staffing review had been carried out in line with the trust safer staffing review process. It had been identified that no uplift to staffing was required based on professional judgement of the team. When necessary staff supported from other hospital sites.

There were dedicated safety huddles each morning. We heard staffing would be reviewed in these huddles on a daily basis and any last minute absences could be reviewed and staff re-deployed accordingly. However, we observed an adult outpatient huddle and did not see evidence of staffing discussed. Following the huddle, we saw that staff were unclear on the whereabouts of one member of staff due on shift.

Managers deployed staff from other areas where possible. Alternatively, one area would be closed and clinics doubled up in other areas to allow for staff oversight of waiting areas. This was not always possible within specialist clinics, for example dermatology where a specific skill set was required. Where appropriate bank staff with the relevant core skills were used.

Staff received inductions and shadowing opportunities when they started.

Staff received and were up to date with most aspects of mandatory training. We saw some training for adult outpatient staff, for example, moving and handling was below the trust target. However, we recognised that there had been some persistent sickness impacting upon completion of training.

Bank staff had been used to cover a number of healthcare assistant shifts. We reviewed training and saw that bank staff had access to, and completed, relevant training.

Staff appraisals were up to date for paediatric outpatient staff. We were not provided with information for adult outpatient services. However, staff told us they had appraisals.

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.

All outpatient areas were clean. Clean stickers were visible and in date.

Cleaning records were up to date and demonstrated that the outpatient areas were cleaned regularly. Healthcare assistants wiped down clinic rooms in between patients and checked each clinic room they were assigned to for cleanliness each morning.

Most furnishings were well maintained.

We reviewed infection prevention and control (IPC) audits and saw good compliance. However, we noted that 2 chairs had been identified in April 2025 as split and requiring replacement. We saw 2 chairs remained in the department at the time of inspection awaiting replacement.

Staff were observed to adhere to IPC principles, including handwashing. However, we saw not all staff adhered to the dress code policy. We reviewed IPC audits and found this had been previously identified on some department audits. This was raised with staff through regular communications.

Localised IPC leads had access to and attended trust wide IPC days.

The electronic patient record system had facility for flagging patients with particular infection history. This allowed for appropriate cleaning following appointments.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

Staff were trained in safe administration of medicines. Weekly medicine management audits demonstrated compliance with the trust’s Medicines Management Policy.

Medication cupboards were locked.

Prescribing was carried out in line with national guidelines. In some clinics, for example, early rheumatology, injections were given.