Victoria Infirmary

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

This means we looked for evidence that people were protected from abuse and avoidable harm.

We last inspected the service in 2014 in combination with diagnostics and with the other trust location. At our last assessment we rated this key question good. At this assessment, the rating has remained good.

This meant people were safe and protected from avoidable harm.

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 evidence showed a good standard. 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.

Staff had access to trust wide policies to support incident reporting and implementation of Duty of Candour. The policies were clear, comprehensive and had been reviewed on a regular basis.

Staff submitted notifications to external bodies as needed. Staff completed incident reports that were uploaded to the NHS learning from patient safety incidents system.

Between April 2025 and March 2026 there were no serious incidents or never events. There were 27 incidents reported; all were graded either as no or low harm.

Never Events are serious, preventable patient safety incidents in healthcare that should not occur if available preventative measures are implemented.

Staff we spoke with knew what incidents to report and how to report them. There was a trust wide poster that summarised the incident reporting process.

Staff received feedback from investigation of incidents, both internal and external to the service. Information was fed back in daily safety huddles that we observed and were included in staff newsletters.

We were given examples of when changes had been made as a result of feedback such as implementation of care rounds and processes to improve the management of patients who arrived by ambulance.

The evidence showed some shortfalls. The service did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

There were trust wide processes to manage referrals of patients who required appointments with consultants. Patients were referred for care either internally or by external routes such as GP’s.

Patient information was recorded in a combination of paper and electronic records. There were different electronic patient record systems dependent on the speciaIity. We reviewed 11 sets of patient records and found that not all vital information was captured in the different systems and was not consistent. This included any known allergies and medicines with not all systems visible to all staff.

In the minor operations area Local Safety Standards for Invasive Procedures (LocSSIPs) and the WHO surgical safety checklist were completed. LocSSIPs are locally developed, procedure-specific checklists designed by NHS organisations to improve patient safety, based on national standards. The WHO checklist is a 19-item, evidence-based tool developed to reduce surgical errors, complications, and deaths by fostering better teamwork and communication in operating rooms. We requested results from any audits. An audit of LocSSIPs in 2025 indicated partial compliance. Following the inspection we received an action plan that included planned improvements. We were not provided with any audits of the WHO checklist.

The evidence showed a good standard. 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.

There were trust wide policies for safeguarding adults at risk of abuse and neglect and safeguarding of children and young people. Information about safeguarding was displayed at the service.

Between April 2025 and March 2026, the service did not report any safeguarding incidents.

Staff were able to describe the safeguarding process, give examples safeguarding concerns and how they would escalate these.

All staff were required to undertake safeguarding training. Safeguarding adults level 2 and safeguarding children level 2 was planned every three years. There was 100% compliance for safeguarding adults level 1 and level 2. There was 1 member of staff who was required to complete level 3, however this had not yet been completed. For safeguarding children’s training, there was 100% compliance for level 1 training and 93% compliance for level 2 training. The clinic staff supported with adult patient appointments. Any appointments for children were booked by external organisations.

The evidence showed some shortfalls. The service did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff used appropriate tools to monitor patients' health.

There was a trust wide policy for recognition and management of the deteriorating patient that included management of sepsis. Between April 2025 and March 2026, there had been no incidences of sepsis for the service

The Minor Injuries Unit (MIU) was open from 9am until 8pm. We observed that patients were waiting to be seen prior to 9am. Staff in the outpatient’s department told us about incidences where patients had needed support from them prior to the MIU opening.

Patients could sometimes deteriorate while at the outpatient department. However, as there was no emergency department at this hospital, staff followed protocol by calling 999 for an ambulance for any deteriorating patient. Advice could be sought from the emergency department for the trust if needed. They provided short term support to these unwell patients while they were waiting. Since January 2026, 5 patients had required assistance from first responders and ambulance transfers. A daily resuscitation huddle had been introduced that identified members of staff in the hospital that would be available to attend to an emergency. The huddle was based in the minor injuries unit, where an Emergency Nurse Practitioner (ENP) was based. Staff in the nominated team carried radios to communicate. The hospital's resuscitation response team were available from 9am until 5pm Monday to Friday.

The opening of additional services at the hospital has meant that more clinical staff are on site in the event of an emergency in out of hours periods.

Training compliance for paediatric immediate life support (PILS) was 75% and paediatric basic life support (PBLS) was 80% which were both below the trust target of 90%. Adult life support was 90% compliant and immediate life support compliance was 100%.

A SOP had been implemented for the first responder pathway across the hospital for patients who deteriorated. This SOP included how emergencies were recognised, escalated and managed, including numbers to call both in and out of hours.

The evidence showed some shortfalls. 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.

Entry to the outpatient’s department was via the main entrance and was clearly marked. Doors were automatic allowing easy access for ambulance trolleys and for people with reduced mobility. Some of the flooring in the entrance was worn although identified with safety tape. Plans to replace the flooring were awaiting approval to implement.

The waiting room was a shared space used by patients awaiting treatment in the Minor Injuries Unit, patients accessing community services provided by Trust staff, patients attending phlebotomy services provided by another NHS Trust, and patients waiting for outpatient clinic appointments.

We observed signage at reception directing patients to services within the hospital that required them to pass through the main outpatient corridor. As a result, there was a flow of patients through the area who were not attending outpatient clinics. We were told that this was the most accessible option available for patients due to other services being delivered and the design of the building.

The department included 9 consulting rooms, 4 rooms dedicated to ophthalmic processes, a treatment room and a day surgery (minor operations) area. There was also a room that accommodated patients arriving via ambulance stretcher.

A fire risk assessment of the hospital had been completed in April 2026 and an updated fire alarm system had recently been installed. There were challenges due to the age and listed status of parts of the building and mitigations had been put in place to reduce the risks. There were notice boards that displayed information about actions in the event of fire including nominated fire marshals.

The trust had identified that not all outpatient rooms were suitable to carry out certain procedures due to the ventilation systems not being compliant with national guidelines. This had been risk assessed and measures were in place to help reduce the risk of any infection as a result of the environment.

Storage rooms were all locked and organised well. However, due to limited space some items, including boxes, were being stored on the floor. We escalated this whilst on site and the items were immediately removed.

We reviewed samples of consumables, in consulting rooms and store cupboards. We found that some had passed their expiry dates. These included urine dipsticks, a box of urine sample bottles, ultrasound transmission gel and optical prisms. Staff told us that these items were not frequently used.

We saw a box of products that looked to be sinus relievers samples in an accessible consulting room. We escalated this whilst on site and the items were immediately removed.

Maintenance schedules indicated routine checks and daily checks completed by staff as well as routine checks for contracted equipment.

Emergency equipment in the resuscitation trolley was checked daily with a full weekly check of contents. Resuscitation information was displayed that included flow charts in case of an emergency and certificates to indicate staff trained in resuscitation skills.

In November 2025, a Patient‑Led Assurance of the Care Environment (PLACE) inspection of the location scored 100% for condition.

The evidence showed a good standard. 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 was calculated according to clinic requirements. The off duty was completed approximately 6 weeks in advance electronically, providing a total of 10 weeks when combined with the current 4 week roster period. These could be subject to changes dependent on demand and availability. The staffing to room ratio was calculated as 0.6 whole time equivalent (WTE) per room each day. There was a total of 19 staff. There was a band 7 nurse manager (1 WTE), band 6 nurses (1.32 WTE), band 5 nurses ( 2.06 WTE), administration support band 2 (1.24 WTE: 0.04 vacancy) and band 3 clinical support workers (CSW’s) or health care assistants (HCA's) (8.84: 0.63 WTE vacancies). There were a number of these staff who worked part-time. At the time of inspection sickness was 11%. There were weekly and monthly meetings to review staff sickness and review of the support for staff who were off long term. The service had a turnover rate of 9%. We were told that the main reasons for staff leaving was either for retirement or promotion. Succession plans were underway that included a review of outpatient roles to develop skills in multiple specialities. Staff could cross cover trust locations if needed, however, bank staff were generally utilised to support shortfalls due to sickness or absence with a workforce of over 50 staff.

Consultant clinics were staffed with registered nurses (RN's) and / or clinical support workers (CSW's) dependent on the need of a clinic. For example, minor surgery required 1 RN and 2 CSW's. For ophthalmology there was a need for 1 RN and 3 CSW's. Clinical nurse specialists and advanced clinical practitioners delivered some clinics.

Boards in the department showed which clinics were in progress and the staff on duty. The display included uniform details so people using the service could distinguish roles of staff.

Staff were required to complete mandatory training at time of recruitment and at designated times thereafter. All staff, including bank staff, completed an induction programme. Overall compliance at the time of inspection was 94%; with a target of 90% We were told that where training was below the target, this was due to long term sickness. Staff completed annual appraisals with compliance at 94%.

Staff were required to complete specific standard competency workbooks for their roles.

Staff achievements were displayed on a ‘What are we proud of’ board. The hospital had created a wellbeing space for all staff to take their breaks. There were posters displayed with information including senior leaders, freedom to speak up guardians (FTSU) and mental health first aid. There was a display board that highlighted stress awareness month. Panic alarms were in consulting rooms for staff if concerned for safety.

The evidence showed a good standard. 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.

There was a trust wide policy for “Infection Prevention and Control Standard Precautions” that was dated for review by April 2026. Following the inspection we were provided with the updated version which had been reviewed in April’s governance process. The department was visibly clean and domestic staff were visible despite some areas being worn such as toilets.

Personal protective equipment (PPE) was available including gloves and aprons in dispensers around the department. Clinical sinks included hand washing instructions and hand sanitisers. Patients we spoke with told us they observed staff washing their hands.

We observed staff were bare below the elbow and followed correct hand hygiene procedures. Staff uniforms were visibly clean, and staff could explain what their role was in infection prevention and control.

Staff understood the polices and processes for maintaining good infection prevention and control.

In consulting rooms where disposable privacy curtains were present, we saw that these were changed as per a routine plan. There was a programme for deep cleaning showers and routine testing of water.

Concerns regarding compliance with ventilation in procedure rooms had been identified and added to the risk register. A number of controls and actions had been put in place to mitigate the risk of infection.

Cleaning schedules and checklists in place were in place and seen to be completed.

Hazardous substances were securely stored in a designated control of substances hazardous to health (COSHH) cupboard in a locked room.

Sharps were disposed of in designated bins and other waste was disposed appropriately according to if clinical or domestic.

Staff completed infection prevention and control training as part of mandatory requirements. Compliance was 94% for level 1 and 93% for level 2.

In November 2025, a PLACE inspection of the location scored 100% for cleanliness.

Audits for IPC took place throughout the year. Hand hygiene audit compliance ranged from 98% to 100%. Uniform audit compliance ranged from 94% to 100%. Compliance for equipment audits had improved from 81% in April 2025 up to 100% by February 2026.

The evidence showed a good standard. The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happen.

Medicines prescribed during outpatient appointments were obtained via a community pharmacy of the patients choosing via a FP10 prescription.

Staff knew how to contact a pharmacist if they required advice about medicines including out of hours.

Medicines were stored securely. Areas used to store medicines had the temperature monitored to ensure this was safe and a system was in place to alert staff if any deviations occurred out of hours when the department was closed.

Clinical support workers were trained to administer eye drops and a clear procedure and competency check was in place to support them to do this. Although the policy stated that the competency would be reviewed, we saw evidence that some staff had not had this competency recorded so we could not be assured they had been completed as per the trusts policy.

Patient group directions (PGD’s) were available for use for the administration of eye drops. We found there was a lack of clarity on how managers could be assured which staff were signed up to work under the PGD if they worked across the trust’s sites, however this was rectified by the trust immediately following the inspection.

Controlled stationary such as prescription pads were stored securely and there was a tracker in place to ensure their use was monitored. Staff completed audits of the security of controlled stationery and action plans were developed following the audits when issues had been found.

The department had recently started to use an electronic system for patient records, and we found that not all records contained information such as allergy status.

Staff recorded incidents related to medicines and when incidents took place appropriate actions were documented.

The service had developed access to patient information leaflets via QR codes so alternative languages and large print could be offered if needed.