Wexham 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 and mostly met people’s needs. However, some areas needed repair, such as flooring and ceilings, and this affected the safety of some patients and staff. 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.

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.

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, and directly to their line manager or member of the senior team. Most staff we spoke with felt that they could speak with their line manager and action would be taken. Staff could tell us about action taken by leaders following issues being raised.

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. Ward 4 was a pilot site for falls prevention after the number of falls increased. Staff were able to describe the measures put in place and outcomes. There had not been a significant fall with harm for over 100 days when we inspected the ward. Ward 5 had input from the clinical education team following a patient who deteriorated suddenly. Their management of a deteriorating patient was refreshed and staff told us they felt more confident of managing the situation should it arise again.

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 medical unit had one patient safety incident investigation per month between October and December 2024 and then one in March 2025.

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. The patient record was updated at the patient’s bedside and requests to other clinicians could be sent electronically via the system. This enabled timely review of the patient. Staff could access patients records from any terminal and therefore specialist teams were able to identify patient who may require their specific expertise.

The therapy service worked with an external community provider to ensure that patients did not experience a gap or break in service. They had reviewed gaps in services and worked with the external provider to ensure that these were managed to provide a safer service to patients. The therapy services provided joint cover such as an occupational therapist completing part of the physiotherapist’s assessment where these provided baseline information for patients. This meant that the patient only had to have a baseline assessment once. The therapy team worked with the practice development staff to support nursing staff to provide a better service for patients such as measuring people for walking sticks and doing simple physiotherapy. A pilot of attending the early handover was undertaken to provide bitesize training to staff. Whilst this increased confidence in the nursing staff this was unsustainable due to the therapy team size.

The Ambulatory Care Unit was located near the emergency department and assessed and treated patients and to allow them to return home quickly. Staff saw between 50 and 70 patients per day during the week. They assessed and treated patients to allow them to return home. Less than 2% of patients were admitted for onward care. The service was staffed by doctors and advanced clinical practitioners during the week but only advanced clinical practitioners at the weekends. The service was open from 9 am to 9pm. They had good working relationships with the emergency department pulling through to the ambulatory care unit appropriate patients. The service had priority access to diagnostic departments. The service had strong links with the community teams 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. However, during our inspection we saw patients in overflow areas including the corridor and in patient day rooms. Senior staff were aware of how many escalation beds they could safely accommodate. There were effective processes to manage patients who were admitted to designated 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. The on-call team were available out of hours and there was a mixed response from staff as to response times.

Staff in the discharge lounge worked 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.During our inspection, the hospital was at full capacity with patients boarding in escalation spaces. During the site meeting on 12 March there was a clear directive for all patients who were being discharged and fit to sit in a chair to be transferred to the discharge lounge. However, we observed the discharge lounge was not fully utilised in the mornings. Staff told us that approximately 30 patients a day went through the discharge lounge but the majority of these were after 11am. The hospital had recently introduced a system where a cardboard coat hanger was placed on the bed of patients who had been identified for discharge. This was to highlight to the patient, family and staff that the patient was ready to be discharged the following day and provide information. Senior staff told us they were still collecting feedback on this system.

Safety information about patients was displayed above their beds. 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 hospital employed eleven nurse consultants who had developed improvements to services and provided specialist care to patients. We spoke with three nurse consultants who were able to outline improvements to care for patients because of their work. This included more complex respiratory patients being treated in the virtual wards rather than being kept in hospital. Complex ventilated patients can be referred more quickly to specialist hospitals due to the nurse consultant building the rapport through demonstration of their knowledge and experience. We also heard about the increased identification of frailty at the front door through the work undertaken by the nurse consultant in frailty.

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 good multidisciplinary working to develop a plan of care for a patient who lacked capacity. The views of the patient, their family and staff caring for the patient were included in the discussion which resulted in a plan of care that everyone agreed.

The service shared concerns quickly and appropriately. Safeguarding policies were known to staff and they understood how to escalate safeguarding concerns about patients. The hospital had a daily meeting about patients who may have mental health needs. Staff reported that the safeguarding team who provided training and support with patients who were living with dementia, a mental health need or a learning difficulty were very supportive in assisting with risk assessments and ensuring a safe environment for patients. The hospital also had a team of healthcare assistants with additional training for patients with mental health needs. There was a clear criteria for using these staff to ensure patients and staff had the right support and care. Resolution of conflict and bespoke training had been developed with the input of a university to support staff. Staff reported that there were good working relationships between the mental health team and ward staff.

The hospital had systems and processes to ensure people understood their rights, including human rights. 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 one patient where there was clearly good multidisciplinary working to ensure the safety of this patient on discharge. They concentrated on improving this person's life whilst protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

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). We asked about the use of mittens and reviewed the policy on use. This stated and staff confirmed that mittens were only used when patients were constantly pulling at lines and then only with a multidisciplinary team agreement.

Staff received mandatory training on assessing the needs of patients who may lack capacity or have mental health issues, but there was further training available. The Mental Health Skills Module (Level 6/7) with New Buckinghamshire University was being undertaken by six staff from the medical directorate at Wexham Park Hospital. The adult safeguarding team delivered a training session promoting the awareness of safe care practices so that staff recognise potential abuse, deepening their understanding of the legal frameworks including the Mental Capacity Act and the Deprivation of Liberty Safeguards.

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 had had life changing surgery and who lived alone in his house was working with the physiotherapist and occupational therapist, alongside the nursing team to be able to return to his home. This patient felt involved in their care planning and an active participant in their care. The family of a patient living with dementia told us how they were involved in planning the care for their parent and how they felt respected for their knowledge of the patient.

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. Monthly audits of National Early Warning Score 2 (NEWS2) were undertaken, and the outreach team undertook daily audits of patients whose NEWS2 score was above 5. Staff knew how to escalate and monitor patients identified as deteriorating or that they were concerned about. Call 4 concern, the service which was widely advertised so that staff, patients or their representatives could raise concerns about the care provided 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. The electronic records system ensured completion of a suite of risk assessments. Due to the system flagging certain patient teams like the dementia team and the frailty team were able to identify and then visit patients who may be at risk of having dementia or frailty. They then worked with the patient and the nursing staff to design a bespoke care plan. The dementia team also provided distraction therapies to those patients requiring them.

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. Housekeeping staff had a daily and weekly rota of items to clean, and this was completed on the ones we saw. Staff had access to equipment and consumables they needed. However, there was insufficient storage space for equipment and consumables. Some wards became even more cluttered when areas used for storage were required for the boarding of extra patients on the ward. This led to safety concerns over ease of access to patient areas and/or in an emergency. There were two wards where we saw ceilings that leaked and floors that were damaged. Bacteria had been identified in some of the sinks on the ward areas. To reduce the risks to patients of infection these had been capped off and made safe. The trust had ensured that there was provision of handwashing facilities for staff but were also reviewing the guidance on waterless hospitals as a measure to address the issues that they had found with waterborne bacteria. These areas were due for refurbishment, but this had been delayed due to the pressures on the service.

There were designated escalation wards for the "winter pressures." However, when we inspected in mid-March these were still open and there were patients who were boarding in areas which were not usually patient areas. For example, we saw that patients were put in the "day room" of one ward. This meant that these patients did not have access to oxygen or suction equipment and at times did not have bed tables or lockers for their personal belongings. The hospital ensured the safety of these patients through appropriate risk assessments and placing of appropriate patients in these bed spaces, liaising with the ward manager.

The equipment we saw was visibly clean. Planned preventive maintenance and electrical appliance tests were completed annually and recorded centrally. We checked equipment and mostly 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. There were effective systems to ensure emergency equipment in medical wards was checked daily. Medical gases were stored securely.

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. Staffing was monitored through governance meetings and by the Director of Nursing to ensure that there were sufficient staff to provide care. We saw that there were sufficient staff on the ward areas. Staff had time to deliver care in a person-centred way and to fully understand the individualities of their patients.

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. Staff had extended competencies to safely care for patients in specific areas of the service such as the coronary care and Acute Ambulatory Care units. Vacancy rates for registered nursing staff were 6% and 12% for unregistered nursing staff.

There were opportunities for development and staff received appraisals. 89% of nursing and administrative staff and 96% of medical staff received appraisals. We spoke with ward managers who told us that there were ample opportunities for development. They were able to list the courses staff had undertaken in the past year. One nurse had been enabled to undertake a number of courses which contributed to them being able to secure a different post in another part of the hospital. The nurse consultants told us that they had been supported to have a national as well as local role. The hospital valued the benefits this could bring to patients.

Staff had completed mandatory training including training to manage risk and incidents. The medical directorate completion rate for mandatory training was 95% this was above the trusts target of 85%. The team were aware of the three 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). Patients who required to be cared for in isolation were able to have single rooms and staff managed infection control practices safely. The department had a designated infection, prevention and control lead and all staff had had relevant training. Cleaning schedules detailed who was responsible for what items and how frequently they should be cleaned. Checklists were in place for cleaning staff to monitor the level of cleanliness. All areas we inspected appeared visibly clean.

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 (December 2024 to February 2025) most wards were consistently over 80% compliant. Where wards were below this measure, additional training and reauditing occurred which resulted in a compliant score. This correlated with the audit for MRSA which showed that in the same period compliance of between 90 and 100%.

Medicines were stored safely and appropriate records were kept, including for controlled drugs. However, the record of the medicine refrigerator on one of the wards showed the staff had recorded the maximum refrigerator temperature above 8*c on several occasions over the past few months. The staff had failed to take appropriate action as per the Trust’s policy.

Emergency medicines and equipment were checked regularly by staff members using an electronic system that used QR codes. However, the staff had to use their personal devices, as the Trust’s handheld devices did not have the functionality to make use of the QR codes. The Trust had identified this and was looking into resolving this.

There was suitable storage and processes to enable patients to self-administer medicines where this was appropriate. The pharmacy teams were available on the wards for clinical and medicines management support Monday to Friday. Nurses were aware of time-critical medicines and used the electronic prescribing and medicines administration system to identify patients with specific needs. Medicines for discharge were supplied by discharge prescription. The pharmacy department responsible for dispensing medicines was fully operational during the week Monday to Friday. Nursing staff coordinated with patients and the pharmacy to ensure that patients had their medication dispensed and weekend discharges were timely.

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 electronic patient record systems were used.