The Royal Orthopaedic 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 safety was a priority for everyone, and leaders embedded a culture of openness and collaboration. We checked that people were safe and protected from bullying, harassment, avoidable harm, neglect, abuse, and discrimination. We also checked that people’s liberty was protected where this was in their best interests and in line with legislation.

The service had a positive culture and reports of good staff morale; people could raise concerns. People were protected and kept safe. Managers had a good overview of incidents, which were investigated thoroughly. Learning needs were clearly identified. The facilities and environment met the needs of people; they were visibly clean and well maintained. Staff received training and appraisals to maintain a good level of care.

At our last assessment, we rated this key question good. At this assessment, the rating stayed the same. 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 service had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety, investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Staff spoke of a positive culture within the service, they felt supported by managers and senior managers.

Staff had a good understanding of how to report incidents; they received feedback on learning from managers. However, the service had staff shortages within the safeguarding team which had impacted on the hospital’s ability to make improvements when risks had been identified.

Staff completed incident reports on an electronic system. The service monitored incidents and identified themes. There were 16 incidents reported between May 2024 and April 2025, 15 of these were reported as no harm and 1 as low harm. The most common reported incident related to the number of rescheduled appointments and patient pathways. The service had a good understanding of the cause and was making changes to reduce these incidents.

Incidents categorised with no and low harm were reviewed by the governance team, senior staff, and the team manager. All incidents graded as moderate harm or above were reviewed in the divisional governance meeting. Incidents were also discussed with staff, and this also identified any learning that needed to take place.

Staff had a good understanding of the duty of candour and when this had to be used. The service reported they did not have any incidents which met the threshold for duty of candour, data showed staff apologised to children, young people, and their families when appointments had been cancelled.

The service monitored National Patient Safety Alerts. Safety updates were communicated by email to all staff.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. Staff made sure there was continuity of care, including when people moved between different services.

The service used a pre-assessment question in relation to mental health, domestic abuse and capacity concerns before admission or as an outpatient. These pre-screening questions provided staff with further information regarding the young person’s needs and how to support them.

The service worked well with external agencies in relation to supporting children and young people to reduce the risk of harm. The service completed a mental health notification if a young person needed mental health support. These were submitted to the safeguarding and vulnerabilities team in the trust to enable them to ensure support was in place where required. They reviewed each notification and completed a care plan tailored to the person’s needs. If deterioration in mental health was identified, staff would contact the young person’s general practitioner for a face-to-face appointment within 24 to 48 hours to access mental health support or liaise with their designated mental health team. The young person was seen either face-to-face by the mental health and dementia practitioner if deemed at immediate risk of harm or contacted over the phone if they required a low level of support and signposting.

There was a standard operating procedure, developed by the safeguarding team, for information sharing for children and young people under the care of the children’s hospital.

The young person and or parents/carers were contacted by the mental health team to gather further information.

The mental health notifications were reviewed daily and assessed dependent on the level of risk.

The service worked well with outside agencies in relation to supporting children and young people with mental health concerns.

The service had good working relationships with the local children’s hospital where children and young people transitioned to if they required more specific care and treatment.

The service had working links with 2 local NHS trusts, with whom they discussed transitions and worked together to develop services.

The service had a transition team which supported young people moving into adulthood. The team also supported children and young people with an additional need. The team spent time with the young person to ensure they understood their care and treatment. The team also worked with families and outside teams including GP’s, social workers, and schools to ensure the young people had a positive journey whilst in the service.

The service looked at referrals for children and young people who presented with a learning disability, disabilities, mental health concerns and safeguarding concerns. To be able to better monitor this, the service set up new notification forms in June 2024, which evidenced that the service had clear records of new concerns, this also identified any action the staff had completed.

The system gathered all the information about the child or young person; this enabled the service to assess individual needs and ensure actions were put into place before the child or young person attended their appointment. If anything, was identified staff would print off the information on green paper for vulnerabilities and purple paper for safeguarding, then place on their record so it was able to be clearly identified by all staff.

The service used paper patient records. We reviewed 10 sets of records, that had correct information collected. All records were up to date, entries signed and dated by staff. All records were stored securely in a locked cupboard. The service told us they were moving to an electronic system in the near future.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff 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 systems and processes within the trust to protect people from abuse. Staff were knowledgeable about the different types of abuse and their role in safeguarding children.

The service had a good understanding of where all 16- and 17-year-old young people were placed whilst on adult wards.

The service had an effective safeguarding alert notification system within the trust. Notifications of concerns were made online, on a paper form and through a duty phone and a dedicated email address that was staffed every day.

The service reported 23 incidents relating to child safeguarding notifications and actions within the last 6 months, these were well documented and shared with the local safeguarding team.

Staff received training specific for their role on how to recognise and report abuse. Staff received mandatory safeguarding children and adults training. The level of training received corresponded to their role. Training rates were 100% for Safeguarding adults and children level 3 and 80% for safeguarding children’s level 2; this was below the trust target of 85%. Safeguarding training was delivered face-to-face by the safeguarding team. There was a level 3 booklet staff could refer back to in practice which provides guidance on internal and external procedures.

The head of safeguarding and vulnerabilities, executive lead for safeguarding and the named nurse for safeguarding were all trained to level 4 and the trust had recently assigned a new named doctor for safeguarding who was training up to level 4 safeguarding at the time of the inspection. The service had policies and processes in place for children and young people who did not attend appointments. If the child or young person failed to attend 2 appointments the service would contact parents or carers, GP’s, schools then raise this with the local social services team who completed lateral checks. This is where they checked with other services involved in the child’s care and treatment to see if there were any patterns that may indicate a child at risk.

Safeguarding staff were visible and known within the hospital, we observed staff greeting the named nurse for safeguarding by name.

Staff told us, they completed a form for all children who were not brought to appointments, and if a child met any of the other indicators of concern such as being known to social services, missing in education, or if there were risk factors identified. They undertook ‘lateral checks’ for these patients. Children for whom a safeguarding notification had been completed had a purple marker on the outside of their paper file, so all staff were aware.

The named nurse for safeguarding told us about how effective these lateral checks had been. “One patient was found to have not been brought to numerous appointments across a range of healthcare services.” This had been brought to the attention of social services who investigated and found significant concerns about the child’s welfare.

Parents were asked to consent to the lateral checks. If the parent did not consent the safeguarding team would risk assess the level of concern and undertake checks if required. Lateral check leaflets were provided to parents, carers and young people to inform them of the safeguarding process. There were four booklets available including suspected non-accidental injury, children in care, lateral checks and home education.

Each department had a safeguarding and a domestic abuse champion. They received bi-annual bespoke training from the safeguarding team. The service had safeguarding information available on every noticeboard in public areas, including information and posters specific to patients with a learning disability.

The service had a good understanding of Deprivation of Liberty Safeguards. Data showed there were no Deprivation of Liberty Safeguard orders put into place for young people aged 16 and 17 within the last 12 months.

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 spoke with 5 children, young people, and their families, and observed 6 clinics. Children and young people told us they understood why they were visiting the service and felt they and their families could ask any questions.

During the clinics we observed staff explaining care, treatment and next steps to children, young people, and their family members. This included the risks associated with any surgeries. This ensured children, young people and their families had the full information to take away and think about in their own time.

The service had a sepsis policy, and the trust provided evidence showing staff acted in line with the policy where patients showed signs of sepsis. The service used the 16 plus sepsis trust screening tool, and sepsis 6 to aid clinical decision making. If a child seen in the outpatient department showed signs of sepsis, they would be transferred to a local children’s hospital.

Sepsis training was not mandated but the trust provided Acute Illness Management (AIM) training and 154 staff in the trust had attended since it had been introduced.

The trust had a sepsis action plan dated May 2025; this had 20 actions which had been split into recommendations, audits, education, governance, and processes. All actions except for 3 had been completed following the red, amber, green (RAG) rating, there were 2 actions which were still red and 1 which were identified as amber, which means these actions had not been completed.

The trust were currently working toward implementing call for concern in line with Martha’s rule. Martha’s Rule is a patient safety initiative to enable patients, families, carers, and staff to request a rapid review from a critical care outreach team when they have concerns about a patient's deteriorating condition. There was 24 hours a day 7 days a week critical care outreach team who attended any medical emergency. They were all advanced life support trained and most had paediatric life support training in order to provide immediate care until an ambulance arrived to transfer the patient to an appropriate location.

The service did not use the Paediatric Early Warning Score (PEWS) as there were no children under the age of 16 year of age who stayed on ward 3, however, the service did use the National Early Warning Score, version 2 (NEWS2) for all 16- and 17-year-olds. Data showed observations for monitoring young peoples’ vital signs and assessing the risk of deteriorating patients were safely undertaken in a timely way.

The service completed monthly audits to monitor NEWS2 completion, for April 2025 the score was 97.8%, for May 2025 this had increased to 99%, and for June 2025 the score was 99.1%.

During the on-site assessment we could not observe any procedures as there were no 16- and 17-year-olds booked in for any surgeries. However, we reviewed the World Health Organisation (WHO) checklists, these are checks the staff complete before any procedure takes place to ensure the correct procedure was being completed. These were completed in line with national guidance.

The service had reported that there had been no physical restraints or chemical restraints undertaken within the children and young people’s services in the last 6 months.

Staff were able to give examples of how they had supported children and young people with their communication needs.

This included spending time with the young person, explaining pre- and post-surgery and what to expect as they were concerned.

Post-surgery, staff explained how to minimise the risk of infections and how to clean their surgical wounds. This calmed the young person and enabled them to understand and look after their own care and treatment.

The service clearly and consistently ensured all care plans and risk assessments were completed and provided support safely.

Children, young people, and their families told us they were given information to help them to make decisions about the care and treatment and any associated risks.

Staff had a good understanding of how to support children and young people who presented to the service with mental health concerns, the service also had a good understanding of gaining support from outside agencies.

All policies relating to managing risk were reviewed by the service and were in date.

The service detected and controlled potential risks in the care environment. Staff made sure equipment, facilities and technology supported the delivery of safe care.

The service had a children and young person’s outpatient’s department situated on the first floor which could be accessed by stairs or a lift. They had one main reception for both children, young people, and adults, with a waiting room. This area had clear dividers separating it from the general outpatients’ waiting area, to ensure the area were visible to staff. There were games available for children to play while they were waiting. The service had accessible toilets, and all areas were spacious.

The waiting area may not have been suitable for children with acute sensory needs due to it being very bright and light-filled on a sunny day, however, the service had a quieter room in which children could wait if required.

The service had a separate area with 3 bays which had a door securing this area, which would prevent adult patients, or any other person without authorisation accessing the area. The service also had a reflection room where private conversations could take place. The children, and young people’s height and weight were taken in this room to ensure privacy and dignity.

The service had a room where dressings were changed. All areas were child friendly and accommodated children and young peoples needs. The dressing room had sensory equipment which helped children and young people to relax.

The service had two wards where children of 16 years and over were cared for if surgery was required. There were dedicated young people side rooms, with space for families, as well as a room for young people to break out.

The hospital grounds were well maintained, with very well-appointed gardens and spaces for people to use. There was artwork and sculptures displayed around the premises, some of which had been created by patients.

The service made sure there were enough qualified, skilled, and experienced staff, who received effective support, supervision, and development. Staff worked together well to provide safe care that met people’s individual needs.

There were staff shortages within the nursing staff, with the data showing the service had 2.8 whole time equivalent vacancies for registered nurses. The team covered the vacancies and shifts were not left short. All nurses who worked in the paediatric outpatients were paediatric trained nurses, including the Band 7. The service had no vacancies for medical staff.

Daily staffing reviews are carried out by the nurse in charge and the Matron to ensure all clinics were safely staffed with the right numbers and skill mix. Where short-term staffing issues were identified appropriate staff to maintain numbers and skill mix are redeployed from the wider outpatient’s team.

There was no dedicated paediatric nurse available 24 hours a day for advice. This was on the service’s risk register and mitigations were in place. No children under the age of 16 were cared for outside of the outpatient facility where paediatric nurses were. The team were supported by a paediatric matron from Birmingham Children’s Hospital once a week.

There were vacancies for clinical nurse specialists, we raised this in feedback with senior managers, and they stated that staff were supplied by a local children’s trust and as part of a joint pathway between both trusts. The clinical nurse specialists acted as a bridge for patients who following being see in the outpatients, underwent treatment or intervention at a different site.

The service used 8.8% of nursing bank staff in the outpatient’s department in the last 6 months, they did not use any agency staff during this period.

The service had used agency staff and bank staff during the last 6 months to support ward 3 and ward 1 which were adult wards. Young people aged 16 and 17 years old would stay on these wards and were cared for on the adult surgical pathways.

The service had 10.8% of staff sickness recorded in the last 12 months. These were all short-term sickness, which the service was monitoring in line with their absence policy.

The service had completed 90.9% of staff appraisals, slightly below the trust target of 95%. However, the trust had recently moved its appraisal window to April and most were due to be completed within the following weeks after the inspection. The service completed group clinical supervisions.

The service completed inductions for all new staff, bank staff and agency staff, to ensure they were aware of the service, and managers were able to sign staff off when they were competent in their roles.

Staff did not always complete their mandatory training and were below the trust target of 93% for 7 training modules. These included infection prevention training, equality, diversity, and human rights and moving and handling level 1.

There were a number of training modules where the trust required 100% target for staff compliance. The service had met all of these except for pressure ulcer care which scored 80%, and patient safety level 2 which scored 0%.

Data showed 91.6% of staff had completed training in learning disabilities and autism awareness which was above the trust target..

The service completed 4 mental health training sessions for all staff, between April 2024 and March 2025 where 65 clinical and non-clinical staff from across the trust attended the training. The training included a person’s lived experiences on how to manage mental distress, suicidal ideation, and difficult behaviours.

The security were employed by an outside agency; however, they were overseen by the trust’s Deputy Director of Delivery and Head of Estates. All training completed by the security team was reviewed to ensure training requirements were met as per their role.

The service assessed and managed the risk of infection. Staff detected and controlled the risk of infection spreading and shared concerns with appropriate agencies promptly.

Staff had a good understanding of policies and procedures in relation to infection control and prevention; all staff were bare below the elbow and wore personal protective equipment (PPE), this included aprons and gloves. The service had completed a personal protective equipment audit which was compliant, however, had not been dated, and therefore we were unable to identify when it had been completed.

All areas were visibly clean and tidy, and all exits were clear. The service had hand gel available in clinical areas and children, young people and family members were able to access this.

The service completed an annual water outlet audit, this scored 100%. However, this had not been dated to show when this had been completed.

The service completed hand hygiene audits from the period of 1 April 2024 to 31 May 2025; these were all 100%.

The service completed an annual infection control and prevention audits including, environment, waste, spillage, linen, and sharps, this identified red, amber, green (RAG) ratings, which were all green except for 4 areas, the overall score was 95%, however, this audit was completed 26 July 2024. They also completed a bi-monthly walkaround with the matron to monitor standards. We saw an email with feedback given to staff following a walkaround. The service were introducing a monthly IPC practice audit that departments completed themselves to monitor IPC practice.

The service made sure that medicines and treatments were safe and met people’s needs, capacities, and preferences. Staff involved people in planning, including when changes happened.

The outpatient’s department only held medication in the resuscitation trolley, which the pharmacy supplied. These were monitored by a tracker with the responsibility from both the service and pharmacy.

The service had 2 antimicrobial pharmacists; the service had processes for reviewing antibiotic prescribing which included documenting a reason for the antibiotic choice.

Young people (over 16 years old) being nursed on the wards within the oncology speciality arrived at the service with a detailed plan from their previous trust, and arrived with their medication, the service held a stock of medication that may need to be started.

All young people (over the age of 16 years) who arrived pre-admissions brought their own medication and were encouraged to get a supply of medication ready for pre- and post-surgery.

The service did not give prescriptions for children and young people under 16 years of age; these medications were administered by another children’s trust or their GP. The service did administer medication for young people 16 and 17 years of age.

The pharmacy were in the process of creating easy read leaflets including pictures for children and young people who had communication difficulties to enable clear understanding of medicines and the side effects they might have. We saw examples of these for common pain relief medicines and found they were very clear for children.