Thomas Linacre Centre

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 good. At this assessment the rating has remained good. This meant people were safe and protected from avoidable harm.

The service ensured staff had sufficient information about the patient to ensure they were treated safely, worked to ensure patients understood their care and could raise concerns, and had a proactive incident reporting culture.

However, there was not always sufficient oversight of medical equipment at the location, meaning some equipment significantly exceeded its intended service date. Staff were not always familiar about emergency resuscitation arrangements, and resuscitation equipment was not always accessible to all staff.

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.

We scored the service as 3. The evidence showed a good standard. The services 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 demonstrated a good understanding of what incidents should be reported and told us they felt confident in doing so. We saw example incident reports which advised staff of when the duty of candour and compassionate engagement processes were required as part of the Patient Safety Incident Response Framework (PSIRF). Staff we spoke with understood the importance of informing the patient in the case of an incident.

In the previous 12 months, the adult outpatients service had reported 73 incidents, of which none had scored a harm level of moderate or above. As such, no incidents that occurred at the location had required specific investigation processes as part of PSIRF. Relevant incidents were reviewed at a divisional level where trends or further analysis could be considered, and these meetings appropriately produced actions with named responsible staff and due dates.

The trust produced monthly patient safety newsletters that were disseminated to all staff, and dedicated face-to-face Learning From Incidents Events were held routinely. The division produced a further bulletin communication which summarised current trends and learning themes based on recent incidents, for the benefit of all staff.

Staff reported that they did not always receive feedback from incidents that they had reported, although they felt that this was likely because the incidents were minor in nature. Staff were confident that in the case of a significant incident, managers would keep them informed of any investigation and learning.

We scored the service as 3. The evidence showed a good standard. 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.

We reviewed the referral policies and procedures of Breast, Ear, Nose and Throat (ENT) and Audiology specialities. Referral routes and admission and exclusion criteria were clearly communicated with reference to national guidance where appropriate, and each document was within its review date.

Clinical staff had access to all useful referral information and relevant patient details prior to seeing them, including assessments such as mental capacity and Deprivation of Liberty Safeguards (DoLS) documentation, clinical risk assessments such as venous thromboembolism (VTE), falls risks, medications records and previous clinic notes.

When making referrals or transitioning patients to other services across primary and secondary care contexts, outpatient specialities referred to clear standards and responsibilities that had been developed by the trust alongside the local authority and Integrated Care Board (ICB). Staff had systems that notified them of when a patient would be attending by ambulance transport or had additional mobility needs and could accommodate this safely throughout the patient journey on the day.

However, we noted that the paediatric outpatient service did not have a dedicated policy or process related to transition to adult services. The provider did not demonstrate that developmentally appropriate transitional care was provided, in keeping with guidance from the National Institute for Health and Care Excellence (NICE) and the Royal College of Paediatrics and Child Health (RCPCH).

A number of key specialities that operated from the location had identified delays in some patient pathways, such as in organising timely follow-ups or producing clinic letters. The service had appropriately reported the associated risks of harm and escalated these where necessary, and existing controls and assurances had been identified and evaluated in these cases.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to understand what being safe meant to them and could share concerns quickly and appropriately when there was a concern.

Nursing and support staff were trained to the appropriate level in safeguarding and could demonstrate good understanding of their responsibilities. We heard examples of how they could identify and help protect vulnerable adults and children at risk of harm, including those with protected characteristics under the Equality Act 2010.

The trust’s safeguarding policy had adopted the ‘Think Family’ approach, which emphasised a holistic understanding of people at risk to better safeguard them. There were clear processes demonstrated for responding to immediate risks and for making safeguarding referrals, and both a duty safeguarding service and a Children in Care (CIC) team were available by phone during typical working hours.

Outpatients services contained useful information on display around safeguarding resources for vulnerable people, and the contact details of the trust’s Independent Domestic and Sexual Violence Advocate (IDSVA) were displayed sensitively in toilet facilities.

Mandatory safeguarding training compliance showed that 63% of consultants and only 35% of resident doctors were compliant with Think Family safeguarding, which was below trust targets. However, we were told this was because the trust had recently transitioned to a new module of training and the data provided did not include compliance with the previous module.

We scored the service as 3. The evidence showed a good standard. 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.

We looked at 9 patient notes and a selection of referrals for different patients during the inspection. The administration of patient notes varied by the speciality present in the clinic and so were in either paper or electronic formats, but medical and nursing staff were aware of these differences and told us they were confident on where and how to find information. We found that patient records broadly contained the correct documentation and risk assessments relevant to the speciality. This included appropriately dated pain, falls and tissue viability assessments, records of previous clinical observations and early warning scores, and medical histories. However, handwritten clinic notes were not always fully legible to staff reviewing them. Both paper and electronic patient records and notes were available and easily accessible by staff when they needed them.

Staff communicated with patients to ensure they understood their care and treatment and gave us examples of how they would adapt their practice to manage patients experiencing anxiety or distress in a positive way. Breast care nurses had a dedicated counselling space where difficult conversations could be had in privacy and comfort and were highly experienced in having these conversations. They recorded these feelings so that future clinicians seeing the patient could prepare for this and provided an easy-access and open-ended service.

Patients told us that they were aware of how to raise concerns or ask questions, and posters were visible in clinic rooms that encouraged patients to do so, as well as how to access advocacy services and the trust’s patient relations team.

We scored the service as 2. 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.

Outpatient services at the location were spread across 2 floors and several different suites which each comprised a distinct waiting room and clinic rooms, with antenatal and paediatric clinics each held in their own dedicated suites. A desk in the main lobby could direct patients to the correct suite, which each had a reception desk for patients to check in at. Parking, signage and facilities were sufficient for patients with a variety of needs, and corridors and waiting areas were clean and pleasant environments throughout.

Fire procedures were effective and extinguishers and equipment to support evacuation were present and well-maintained. General health and safety, Control of Substances Hazardous to Health (COSHH) and waste disposal risk assessments and audits were conducted regularly, and these had recently been reviewed independently by the trust’s health and safety team or an external provider. We noted that the building’s security arrangements had recently changed. While the trust provided evidence that the risks associated with this change had been sufficiently considered and that a twice daily patrol would continue to take place, further elements of this concern are addressed in the ‘Freedom to speak up’ section of this report.

The paediatric suite was securely accessed by keypad and had a dedicated waiting room that was decorated and designed to meet the needs of children. However, space limitations meant there was no dedicated quiet area for children that required this, and a lack of sufficient soundproofing in one clinic room where attention deficit hyperactivity disorder (ADHD) assessments were completed meant that staff and patients were obliged to remain quiet in surrounding areas to avoid jeopardising the testing. Audiology booths did have dedicated soundproofing, and the spaces were designed appropriately for accurate hearing testing.

Outpatient areas had 3 resuscitation trolleys and 4 automated external defibrillators (AEDs) which were each checked routinely by nursing staff. However, they were stored in areas requiring keycard or keypad access, which was not in keeping with Resuscitation Council guidance due to the risk of delays in accessing emergency equipment. Moreover, staff across the building were not always clear on emergency arrangements and some could neither independently find nor access the resuscitation equipment, when asked. During the inspection, the trust informed us that they were planning to take the resuscitation trolleys out of use in most areas as they were unnecessary for an outpatient environment, and thereafter only keep equipment that was operable with basic life support training (such as AEDs) in dedicated cabinets, with improved signage.

The trust provided inspectors with an asset register of the equipment requiring servicing at the location, which contained over 400 individual devices. It was not clear if the equipment listed was all still in clinical use, and the governance of these assets as demonstrated by the register was poor. As such, during the inspection we identified a portable urine flowmeter that was overdue its intended service date by several years and still in routine use. We informed the trust of this, and they took action to ensure it was serviced prior to its next clinical use. However, the asset register indicated that various other key equipment used clinically was also overdue its service date, such as a foetal heart detector, an ECG recorder, multiple urine analysers, and an electric patient hoist. We noted that the trust had a medical equipment management group that had considered the risks associated with the accuracy of the trust’s equipment asset register, although did not see what measures the trust had taken to address this.

We scored the service as 2. The evidence showed some shortfalls. Mandatory training compliance of medical staff groups was not always sufficient to support safe care. As such, the service did not always make sure there were enough qualified, skilled and experienced staff. The service also did not always make sure staff received effective support, supervision and development opportunities.

Staffing levels:

The outpatient service within the scope of inspection consisted of over 30 clinical staff, which comprised an outpatient lead, a nurse sister and the remainder either registered nurses or healthcare assistants and associates. Medical staff oversight was managed by a different governance stream, which allocated consultants and other medical grades to specific clinics in accordance with their job plans.

Direct operational oversight of the outpatient service was managed by the outpatient lead, with additional leads covering the antenatal and paediatric suites. The service did not routinely use agency or bank staff although would sometimes draw staff from other areas in the case of unplanned absences. The outpatient lead organised and staffed additional clinics to meet the demands and pressures of various specialities hosted at the location, sometimes at short notice. While this process wasn’t led by a recognised staffing tool, the outpatient lead could describe the different staffing requirements of each clinic and had developed alongside others a ‘department map’ spreadsheet to better visualise staff rotas and allocations in real-time. Operational oversight is described further in the ‘Governance, management and sustainability’ section of the report.

The staffing establishment of the breast care nurse team had been reviewed in 2025 against national guidance, which had identified a significant shortfall and accordingly recruited 2 additional band 6 permanent posts, although this was still short of the establishment referenced in their guidance.

Staff training:

Staff were assigned core statutory and mandatory training modules that were aligned with the UK Core Skills Training Framework (CSTF) as well as additional local e-learning modules. Outpatient leads had responsibility for ensuring compliance with this for the non-medical staff group they had oversight of. Outpatients staff demonstrated an excellent overall compliance rate of 98% for all assigned modules recorded, which was above trust targets.

However, medical staff who attended the location could not always demonstrate compliance with the national mandatory training schedules. The average compliance of all modules for all medical staff was reported to be 69%, and 5 such staff had overall compliance rates below 25% against a trust target of 90%.

Employees of the trust were contractually required to join the DBS update service as per their recruitment policy, and the trust followed NHS employment check standards. We saw examples of completed induction and supervision forms for new starters in the department, with a comprehensive checklist which included introduction to a departmental ‘buddy’ for peer support and guidance.

We scored the service as 3. The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading by auditing the environment and staff practice.

All outpatient areas we inspected were clean, with stocked handwashing facilities in both public areas and toilets. Furniture was appropriate for the environment and was in good condition. Cleaning records were up to date and demonstrated that this was undertaken regularly, and we found ‘clean’ stickers that were in date on appropriate equipment. Water flushing records were up to date and demonstrated that this was being done so regularly to control the risk of exposure to pathogens, in line with the trust’s management of water systems policy.

Staff followed ‘bare below the elbow’ guidance and broadly maintained good infection prevention and control (IPC) practice, although we did at times see staff undertake phlebotomy procedures and then continue to wear personal protective equipment (PPE) such as disposable aprons in corridors and waiting areas, which is not in line with NHS England’s National Infection Prevention and Control Manual (NIPCM).

Staff had appropriate training in IPC level 1 and 2, and we saw evidence of annual spot audits of each area, conducted independently by the trust’s IPC team. Compliance was good and no major concerns had been highlighted, and each finding was documented in an action plan with timescales for completion.

We scored the service as 3. The evidence showed a good standard. The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

Staff in outpatients were compliant with medicines safety mandatory training, and medicines stock was secure, organised and in date. We saw evidence of appropriate fridge temperature checks, and staff could describe and demonstrate good practice in medicines governance. There was no pharmacy at the location, and no controlled drugs were stored on site. Prescription stationery was stored in a secure location. The location had recorded 7 incidents relating to medicines in the last 12 months, mostly within the antenatal suite, all of which were graded as no harm.

The trust had an effective medicines management policy and a trust-wide procedure for ensuring local compliance with medicines. A monthly inspection of safe and secure medicines handling was undertaken by a pharmacy assistant of each area of the location. These inspections demonstrated continual good practice, with minor findings acted on by the next inspection.