Frimley Park 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

At our last inspection we rated this key question Good. At this inspection the rating has remained Good.

We rated safe as good. We assessed eight quality statements. There was a positive learning safety culture where events were investigated, and learning was embedded to promote good practice. Staff were open and honest when things went wrong or could be a risk. Staff provided safe care and treatment. The environment was safe, maintained and mostly met people’s needs. Leaders monitored staffing levels to keep the department and people safe. Staff were trained and competent and had the right skills to meet people's needs. They had the opportunity to learn and gain experience. We saw evidence that people were protected from abuse and avoidable harm.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff were encouraged and confident about raising concerns. These were taken seriously, investigated and people received feedback. There were several ways in which people could raise concerns including, freedom to speak up guardian route, the safety huddle, which occurred daily, and directly to their line manager or member of the senior team.

Staff were aware of and confident to report incidents using the trust's electronic incident reporting system. Feedback from learning responses was provided in daily safety briefings and emails to staff. This included learning from other areas of the trust when this was applicable. Some staff were not able to give examples of learning from incidents when asked. However, most staff saw the reporting of incidents as an opportunity to learn and safety huddles as a way of sharing the learning. An example of this is the work undertaken on G2 in respect of falls. Staff have moved patients at higher risk of falling into a single bay which is then closely observed by all staff. This has significantly reduced the numbers of falls on the ward.

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. The lessons learnt were shared with others to continually identify and embed good practice.The service had established a Call 4 Concern service which was widely advertised so that staff, patients or their representatives could raise concerns about the care provided. These concerns would be investigated firstly to ensure the safety of the patients and then to address any issues in the ward or department in a supportive manner to enhance care given to all patients. The service was able to demonstrate reduced instances of avoidable harm because of this initiative.

In April 2024. the trust transitioned to the NHS England’s Patient Safety Incident Response Framework (PSIRF). This meant the trust focused on effective learning and compassionate, meaningful engagement with those affected when incidents occurred.There were several ways that learning was shared across both the service and trust wide. These included safety alerts encrypted electronic messages, safety huddles, handovers, safety snippets, patients' safety briefing forums, patient stories and posters on the back of staff toilet doors. There was a central log of National Patient safety Alerts, which were shared with staff and actioned as appropriate.

The service worked collaboratively with internal colleagues and external partners to maintain patients’ safety. Continuity of care was maintained by effective handover of patients and their individual needs. Alerts on the electronic patient record enabled staff to be aware of and follow specific care plans if a patient had needs that required additional support or there were signs of deterioration.

Senior medical staff had set up and embedded virtual wards and a Same Day Emergency Care (SDEC) service which aimed to prevent hospital admissions. The virtual wards service supported 250 people to receive hospital care in their own homes and whilst admission rates had not gone down, the service had prevented a surge of admission during Quarter 3 2024/25.

The medical and frailty SDEC services saw patients from emergency department, GP’s and community referrals to assess and treat patients and to allow them to return home. The medical SDEC was staffed by doctors and advanced clinical practitioners during the week but only advanced clinical practitioners at the weekends. The service was open from 8 am to 9pm. They had good working relationships with the emergency department pulling through to SDEC appropriate patients. The service had priority access to diagnostic departments. The aim of the SDECs was to reduce the number of patients treated within the emergency departments and reduce admission to hospital for care that can be provided in a same day emergency care setting. The admission rate had increased from around 3% admissions in October 2024 to 6% in December 2024. The service had strong links with the Intravenous Administration Service (IVAS) and the Hospital@Home service to support patients in their own homes.

There were good working relationships within the hospital to manage flow through the hospital. There were board rounds at regular intervals throughout the day to ensure that patients waiting admission or discharge were facilitated in a timely manner. The site team undertook regular walk arounds to identify potentially available beds and support ward staff in discharging patients. The number of patients without criteria to reside was relatively low (10%) compared with the England average and we did not see that medical patients receive corridor care on medical wards. Senior staff were aware of how many escalation beds they could safely accommodate. There were effective processes to manage patients who were admitted to wards outside of the clinical speciality sometimes referred to as 'medical outliers'. Effective systems supported daily reviews (Monday to Friday), and staff were aware of how to escalate concerns about patients whose condition deteriorated. However, patients told us that the reasons for moving bays were not always communicated effectively.

Staff in the discharge lounge worked effectively to facilitate on-the-day discharges including liaising with the pharmacy department to ensure medicines to take home were ready, ambulance liaison for transport and communicating with families to ensure they were aware of the discharge of patients. Safety information about patients were displayed above patient beds. For example, in the stroke unit information about the need to use thickeners in patients' hot or cold drinks were displayed and in G2a ward the risk for falling was displayed to highlight a need to staff. Risk assessments were completed for all patients and care plans reflected individual needs. The electronic patient record recorded these assessments for all care givers to see. We saw evidence of the review of risk assessments as the patient's condition changed.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Each ward area had a board meeting which reviewed every patient and discussed their care plan. We attended a number of these, and it was clear that the safety of the patient was at the centre of care. As an example, we heard that there were safeguarding concerns around the family of a patient and how the hospital was involved in mitigating these concerns.

The service shared concerns quickly and appropriately. Safeguarding policies were in place and known to staff. Staff understood how to escalate safeguarding concerns about patients. The hospital had a daily meeting about patients who may have mental health needs. Whilst the hospital continued to support their teams to develop the skills to support patients with mental health needs, there was a pool of trained healthcare assistants who could be used where necessary. The need for these supporting staff was assessed using a checklist which was reviewed by the approving person to access this pool of staff. Resolution of conflict and bespoke training had been developed with the input of a university to support staff.

Systems and processes to ensure people understood their rights, including human rights, were in place. The site team were responsible for ensuring that patients who were detained under the Mental Health Act understood their rights. The site team took the lead in supporting staff with patients who were also suffering mental health needs. We spoke to and reviewed the care of 1 patient where, despite good working relationships with providers of mental health services, it had not been possible to discharge a patient to a safe place in the community. There appeared to be little resolution to the complex needs of this patient.

The hospital had a working group looking at violence prevention to ensure any restraint used was clinically led. Staff demonstrated a good understanding of Deprivation of Liberty Safeguards (DoLS) and spoke of how decisions were made in the best interest of patients. When this was applicable, staff demonstrated a good understanding of the mental capacity assessments and the use of advocacy services such as services such as Independent Mental Capacity Advocates (IMCA).

The service always worked with people to understand and manage risk by thinking holistically. Staff spent time with patients to understand their individual needs and during board rounds this was evident that patients were at the centre of their care. For example, a patient who was at the end of their life did not want to be placed into a side room as they wanted to be near people. This was considered when transferring the patient to a longer stay ward.

Leaders and staff could articulate what risk assessments they used to keep patients safe. The electronic patient record flagged when patients were at risk of deteriorating and the outreach team actively sought out those patients whose risks were increasing. The critical care outreach team conducted audits of the patient management system on a twice daily basis. This provided a safety net for patients at risk of deterioration.

The audit of National Early Warning Score 2 (NEWS2) of where a NEWS2 score was above 5 showed that between 23 November 2024 and 3 February 2025, 78 patients were identified. The outreach team then assessed and dealt with these patients. Staff knew how to escalate and monitor patients identified as deteriorating or that they were concerned about. Call 4 concern was well embedded in the culture of the staff and was clearly displayed to patients and their families. Concerns raised with this team were treated seriously and investigated to manage any risks.

The service used an electronic patient record system which enabled staff to be aware of specific risks for patients. For example, if patients were at the end of their lives, living with dementia or at risks of falls. Staff had a person-centred approach and involved patients, where possible when completing risk assessments. Patients we spoke to said that they had been involved in planning their care.

The department areas looked visibly clean, and we saw cleaning staff in most wards and departments. Medical wards appeared clean and free from dust including in hard-to-reach places. Staff had access to equipment and consumables they needed. However, there was limited space for the storage of equipment and consumables. Some wards appeared cluttered when patients needed a lot of equipment alongside their personal belongings around the bedspace.

The equipment we saw was visibly clean. Planned preventive maintenance and electrical appliance tests were completed annually and recorded centrally. We checked equipment and it had undergone electrical safety checks within the last 12 months. The department's fire safety equipment and emergency systems such as call bells, were tested and maintained appropriately. However, staff did not always remove equipment (chairs) when they were broken although they reported it. There were effective systems to ensure emergency equipment in medical wards was checked daily. Medical gases were stored securely.

The environment was old, and the hospital were using all available space for patient care. The SDEC had moved on several occasions and whilst sited near the emergency department was not always appropriate for the needs of patients. The waiting area was small and often full and there were chairs in the department for patients to sit on to be examined which did not have any curtains or privacy screens to ensure the privacy and dignity of patients using this area. Similarly, the discharge lounge was often used as an escalation ward overnight. When this happened, staff ensured single sex accommodation only. Patients had access to a toilet and handbasin (no shower) in the discharge lounge. Staff had access to hot and cold drinks and snacks that they could give to patients who were in the discharge lounge either awaiting discharge or overnight. We discussed this with the management team, and they were aware but were balancing the confines of the hospital against the increasing needs of patients.

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 planned and managed according to national guidance. Leaders used recognised staffing tools to ensure that there was enough staff to deliver care and treatment.

Staffing was discussed in regular site management meetings at trust level so that staff could be deployed if needed. We saw examples of when staff were redeployed into areas requiring support following these meetings. meetings. Staffing was monitored through directorate governance meetings and the Head of Nursing to ensure that there were sufficient staff to provide care. Where necessary, temporary staff were utilised, but this consisted mainly of bank staff who were employed by the hospital. Agency usage was less than 3% for nursing staff and less than 1% for medical staff (November 2024 to January 2025). Staff had extended competencies to safely care for patients in specific areas of the service such as the coronary care and SDEC units.

There were opportunities for development and staff received appraisals. Senior staff on the stroke unit spoke of staff being supported to progress their career through apprenticeships so that the trust could 'grow their own nurses'. On the coronary care unit, a member of staff told us that she had been supported to develop a new role allowing her to progress her career without leaving her patient facing role.

Whilst staff were noticeably busy and worked under pressure there was a good degree of support and mutual respect among staff working in the service. When asked about the mutual support available within the hospital the staff stated that every patient is our patient.

Staff had completed mandatory training including training to manage risk and incidents. The medical directorate completion rate for mandatory training was 93% this was above the trusts target of 85%. The team were aware of the two areas that were below target and was addressing this. The trust had a system by which patients needing a greater level of observation were assessed and the appropriate staff allocated. Risks were communicated at handover and at board rounds.

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. Staff followed infection prevention and control (IPC) guidance, washed hands between patient contact and wore appropriate Personal Protective Equipment (PPE).

Signage for sanitiser bottles could have been improved as it was not always clear where these were located. Patients who required to be cared for in isolation were able to have single rooms and staff managed effective barrier nursing. Leaders cohorted patients who had tested positive for Covid 19 to manage the risk of infection. Staff working in and entering these cohorts had access to enhanced PPE such as specific surgical masks in line with national guidance. The department had a designated infection, prevention and control lead and all staff had had relevant training. Cleaning schedules were in place and followed.

The trust monitored the number and type of infections seen in the hospital. Regular audits were undertaken by the teams in the clinical areas and by the infection prevention and control team. Hand hygiene and environmental audits including equipment audits were carried out. The results of these audits were discussed with the relevant departments and an action plan to identify areas of deficit agreed. Random sampling of hand hygiene audits in the medical service demonstrated that in the last three months (November 2024 to January 2025) the wards were consistently over 80% compliant. This correlated with the audit for MRSA which showed that in the same period compliance of between 90 and 100%.

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 happened.

Medicines were stored safely and appropriate records kept, including for controlled drugs, medicines requiring refrigeration and emergency medicines. Ward staff were able to access medicines from other wards if needed to reduce delays in administration. There was suitable storage and processes to enable patients to self-medicate where that was appropriate.

The pharmacy teams were available on the wards for clinical and medicines management support. Nurses were aware of time critical medicines and used the electronic patient record (EPR)system to flag patients with specific needs. Medicines for discharge were supplied from the ward or by discharge prescription. Patients on SDEC could be supplied with a prescription to take to their community pharmacy to assist with discharge. These prescriptions were supplied and recorded appropriately.

Some patients went to the discharge lounge to await their medicines and transport. Nurses in the lounge coordinated the discharge and checked that patients left with the correct medicines and information. They also ensured that patients received any additional support or training for using their medicines safely.

There was a supportive culture regarding reporting and learning lessons from medicines incidents. Regular audits supported safe care, for example on the administration of time critical medicines. Medicines optimisation featured in many trust quality improvement initiatives, including changes to how the EPR and a different information technology system worked together to support shared care with GPs after discharge.

We saw that medicines trolleys in medical wards were kept locked and tethered when they were not in use. Patients told us they received their medicines regularly and received additional painkillers when or if they needed it. Time critical medicines were an area of focus for the Medication Safety Decision Board Members. This safety workstream will expand in 2025/2026 to bring together colleagues across the ICB, the pharmacy team, ED staff members. This was to ensure a breadth of experience and knowledge to improve the patient experience.