St Helier Hospital and Queen Mary's Hospital for Children

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 people’s liberty was protected where this was in their best interests and in line with legislation.

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

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. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The service had a positive culture of safety and learning. Staff were encouraged to report incidents and generally felt confident to raise concerns without fear of blame. This was supported by sharing lessons through daily huddles, team meetings, a learning from incidents newsletter, and regular audit days for each surgical specialty ensuring staff were informed and improvements were embedded.

We saw clear examples of learning from incidents. For instance, after a patient with a learning disability received medication incorrectly and experienced complications with a nasogastric tube, the team introduced changes such as ensuring the use of patient passports and reinforcing correct medication routes. The nutritional team also visited wards to share best practice.

There were arrangements for identifying, recording, and managing risks, issues, and mitigating actions. We saw evidence that the service regularly reviewed safety and incidents through their Divisional Incident Review Group.

In the 12 months prior to the inspection, there had been 2 never events in theatres at St Helier Hospital, a wrong site surgery incident and retained swab. These are serious, preventable patient safety incidents that should never occur, if the available preventative measures are implemented. We saw evidence never events were thoroughly investigated with areas for improvement and safety actions identified.

Staff described opportunities for continuous improvement. Incident reviews were carried out for falls, and findings were shared with teams through team meetings and newsletters. Quality improvement initiatives were implemented to enhance compliance with sepsis protocols and escalation procedures, evaluate current practices against NICE standards, and identify opportunities for better adherence to best practices concerning the administration of intravenous paracetamol. Staff felt supported by visible leadership and described the environment as collaborative and focused on patient safety.

When things went wrong, staff apologised and gave patients honest information and suitable support. We saw examples of thorough investigations of incidents being undertaken and examples of where duty of candour had been applied.

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.

Systems and processes to support safe care and patient flow were in place, but they were not always effective due to operational pressures. Staff worked collaboratively and communicated well within multidisciplinary teams, and patients were involved in discussions about their care. However, challenges in managing patient flow and discharge created delays and increased risks.

The Surgical Ambulatory Care Unit (SACU) was designed for rapid assessment and treatment, but it was often used for inpatient care because of bed shortages. During our inspection, as many as 7 surgical inpatients were accommodated in SACU, an 8-bay outpatient unit, for periods of up to several weeks. This exceeded the six escalation bed spaces allocated to SACU under stage 3 of the trust’s full capacity protocol. This reduced space for ambulatory patients and caused delays in treatment. While staff completed risk assessments and admitted only low-risk patients, the unit lacked essential facilities for longer stays, such as inpatient beds and hot food provision. However, the ward was situated next to the Mary Moore Ward and patients had access to shower facilities and hostesses provided hot food and drink for patients using a kitchen on the Mary Moore Ward.

Recovery staff also raised concerns about patients who were cared for in the recovery area for extended periods due to a lack of beds in the Intensive Therapy Unit (ITU) and High Dependency Unit (HDU). This was not a suitable place to care for these patients because recovery areas are designed for short-term post-operative care, not for managing high dependency needs. This could increase risks to patient safety and quality of care, as the recovery area lacks the necessary facilities, equipment, and staffing levels required to appropriately monitor and treat patients with higher acuity needs. However, leaders told us that when this occurred, patients received additional support from the Critical Care Outreach Team (CCOT) or ITU staff, which helped to mitigate some of the risks associated with extended recovery care.

Directorate leaders engaged with external stakeholders during multi-agency discharge events (MaDE), which were undertaken as required. Leaders told us such events resulted in improved bed capacity and improved discharges, but this progress was not sustained. We received positive feedback from staff regarding communication and multidisciplinary team working. There were weekly complex patient discharge meetings every week, including multi-agency teams and community partners. We saw that the service worked collaboratively and in a joined-up approach regarding safety that involved patients along with staff and other partners.

Clinical escalation pathways were clear and well understood. In emergencies, staff contacted the critical care outreach team and surgical team immediately, and both responded promptly. Staff reported confidence in these processes, which were supported by proactive monitoring of deteriorating patients. However, delays in theatre lists and issues with electronic systems occasionally impacted on timely care. An audit in August 2024 showed that of 57 sessions there were 42 recorded late starts, with the reasons including sessions overrunning, staffing issues and estate issues. The average late start was 16 minutes. This was reaudited in November 2024, the audit showed some improvement and showed that of 117 sessions there were 84 recorded late starts. The average late start was 13 minutes. Following the inspection, the provider outlined ongoing measures to improve theatre efficiency and utilisation, including a late-start workstream and the reintroduction of weekly theatre performance meetings.

Staff told us of new initiatives whereby advanced clinical practitioners would assess the list of patients in the emergency department and would bring appropriate surgical patients to the SACU to relieve pressure on the ED, which staff reported was working well. Flow and discharge coordinators worked to improve flow and reduce delays, although social care and limited rehabilitation facilities for patients remained a significant barrier. The service had a consultant of the week across all specialties on duty who would perform a ward round every morning to determine patients who were fit for discharge. We observed that when beds were at capacity, escalation spaces were used to accommodate additional patients, staff informed us they carried out checks every 2 hours because these escalation spaces did not have call bells. However, the extent to which these two-hourly checks were monitored was not clearly defined. Upon review, it was noted that the trust's Full Capacity Protocol and Patient Boarding Standard Operating Procedure relied on standard ward monitoring practices.

Compliance with safeguarding training was poor in key staff groups, which meant not all staff had the necessary skills to recognise and respond to safeguarding concerns. However, the service worked with people and partners to understand what safety meant and how to achieve it. They focused on improving people’s lives while protecting people’s rights to live free from harm, abuse, and neglect. Concerns were shared quickly and appropriately.

Staff received training specific to their roles on how to recognise and report abuse. However, training completion rates were low for some groups within the division, including level 1 safeguarding training for administrative and clerical staff and safeguarding children level 2 for medical and dental staff. The completion rate of level 3 safeguarding training for adults and children was low among nursing (69%), medical, and dental staff (47%). This was partly due to the recent launch of a new level 3 safeguarding training program, but plans were underway for staff to schedule and complete their training. However, these plans were not explained or shared in a way that assured they would lead to meaningful improvement in compliance.

Staff demonstrated awareness of the needs of people with additional vulnerabilities, such as those with learning disabilities or mental health conditions. Specialist teams were available to support care planning, and staff worked with external agencies when required. Staff understood their safeguarding responsibilities and knew how to escalate concerns. They were able to describe the process for making referrals using electronic systems and gave examples of safeguarding cases they had managed. Training was available, and staff felt confident recognising signs of abuse or neglect, including domestic violence.

The service had established clear processes for identifying and reporting safeguarding concerns, supported by accessible policies available to all staff via the intranet. Leaders provided oversight of safeguarding processes and ensured staff had access to specialist advice when needed. They monitored safeguarding performance through quarterly reports and committee reviews, ensuring that concerns were escalated and investigated appropriately. Reports we reviewed indicated safeguarding risks in the division included poor communication with services on discharge and unwitnessed falls. Risks were monitored through incident reporting and ward dashboards.

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 were aware of and understood escalation protocols for deteriorating patients and the use of NEWS2. Patient records we reviewed had NEWS2 scores recorded in a timely manner and staff acted on increased scores where this alerted them to possible or emerging risks. Audit results indicated that compliance with NEWS2 protocols needed improvement as compliance was 76.7% between April and July 2025, falling short of the trust's target, and no further NEWS2 audits had been conducted since July 2025. A sepsis pathway and screening tool were in place but limited electronic data capture meant service level audits on sepsis management were unavailable. As a result, the service was unable to verify its compliance with best practices; however, specific reports were being prepared in collaboration with the trust reporting team. Data from March 2025 for all inpatient and emergency settings across the trust showed most patients received timely antibiotics, and high-risk cases received prompt senior reviews to support rapid treatment decisions. We did not see there was action plan to address the challenged timely antibiotic delivery. Although work was ongoing to develop focused reports of overdue doses and doses recorded as “not done”.

Risk assessments were completed for most patients. Risk assessments, such as those for Venous Thromboembolism (VTE), were not always consistently completed or reviewed. Between September and November 2025, no surgical ward at St Helier met the 95% target for VTE assessments within 14 hours of admission. Audit data showed compliance ranged from 77% on Mary Moore Ward in October to 84% on the SACU in September.

The theatre department followed the National Safety Standards for Invasive Procedures 2 (NatSSIPS 2). These are designed to reduce misunderstandings or errors and to improve team cohesion. NatSSIPs2 help achieve the goals of improved patient safety, better team-working and enhanced efficiency. The team also undertook the World Health Organisations checklist before and after each operation. We saw examples of appropriate safety checklists which were in use within interventional radiology. Staff in the SACU informed us that they did not use formal checklists when performing incisions and drainages. The absence of a structured checklist increased the likelihood of important steps being overlooked during critical phases of treatment, potentially affecting patient safety and care quality. However, staff stated they were unaware of any incidents resulting from this practice.

We reviewed audit data for surgical safety checklists. The last audit of WHO checklist compliance occurred in April 2025. While the data did not provide specific figures to assess themes and trends specifically within St Helier theatres, most non-compliance issues across the sites audited stemmed from a lack of team engagement and some staff members not being present. This audit occurred before the new electronic patient record system was introduced. Most staff complied with the WHO checklist and National Safety Standards for Invasive Procedures (NatSSIPs 2), although we observed one instance where checks were performed from memory instead of using the checklist. This increased the risk of important safety steps being overlooked, potentially leading to avoidable errors or harm to patients. Consistent use and engagement with the provided checklists are essential to ensure all safety measures are followed, minimise the likelihood of incidents, and maintain high standards of patient care and safety.

People were generally involved in decisions about their care and informed of any risks. Staff explained procedures and medicines clearly, and patients reported feeling informed and reassured. Observations showed staff discussing treatment plans and providing updates during delays, which helped maintain trust and confidence. Information was provided through verbal discussions and supplementary leaflets, ensuring patients could make informed decisions. We observed consent forms were completed appropriately, with key risks clearly identified.

Staff also adapted care for people with additional needs, such as those with dementia or learning disabilities. Patient passports could be used to ensure personalised care, and specialist teams provided input where required. Feedback from patients indicated they felt listened to and involved in decisions about their treatment.

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.

Clinical areas were generally clean and well maintained, but space constraints created challenges. We observed that some theatres were cluttered due to insufficient storage. Additionally, ophthalmology lenses were not stored according to best practices, increasing the risk of selecting incorrect lenses. The design and age of the theatre environment at Epsom and St Helier Hospitals had been identified as a risk due to inadequate storage, shared movement routes (where clean and contaminated items, equipment, or staff use the same pathways without clear separation), and lack of continuous ventilation monitoring. These issues can increase the potential for infection, trip hazards and obstruction of escape routes. Recent ventilation and environmental inspections across St Helier theatres showed that operating theatres largely met standards for proper ventilation, However, the recovery area was found to be non-compliant in extract ventilation rates and noise levels. Although an action plan was established to address issues related to heating, ventilation, and air conditioning, most scheduled tasks were not completed by their target deadlines, and remediation work had yet to commence.

The environment on the SACU was cramped especially as at the time of the inspection; this area was being used for inpatient care despite not being fully designed or equipped for prolonged stays. There was also a lack of dedicated staff rest areas on the SACU. Staff told us this made it difficult to take breaks away from clinical spaces, which could affect wellbeing and increase fatigue during busy periods. Escalation bed spaces used on surgical wards to improve flow from the emergency department lacked basic facilities such as call bells. Although staff mitigated these risks by performing two-hourly checks and ensuring only patients who could call for help and with reasonably good mobility were placed in these areas. Despite these limitations, patients reported feeling safe and cared for. On Ward B3, emergency call bells were not audible to staff in half of the ward, which meant people could not reliably summon help. This increased the risk of delayed response to urgent needs and compromised patient safety. We also observed that on the Mary Moore Ward, rooms that previously accommodated a single patient were assigned to two patients (“double up” rooms). This created a cramped environment that restricted space for staff to attend to patients during a medical emergency. Staff told us about a recent incident where this risk materialised, but the impact was reduced because the neighbouring patient was mobile and able to leave the room and wait outside.

There was no data available to demonstrate that audits assessing compliance with infection control standards had been completed. Cleaning schedules were inconsistently displayed in bathrooms, and those present were often not updated, indicating lapses in monitoring cleaning processes. Dirty utility rooms were clean and substances hazardous to health were well managed. We also checked various consumables and found the majority were sealed and in date.

Environmental risk assessments were performed, however there was no documented hot water scalding assessment in place. Fire safety assessments for B4 and A2 theatres identified concerns including storage of combustible items in escape corridors and damaged fire doors. Action plans were established to mitigate the risks identified in theatre fire risk assessments; however, many actions are still in progress. We also observed that some clinical areas experienced extremes of temperature, which staff told us was due to ageing infrastructure. These issues increase the risk of harm to people, including potential infection, fire hazards, and discomfort, which could compromise patient safety and the quality of care.

Security protocols were in place, requiring swipe cards for entry and exit, with patients using an intercom system. Emergency trolleys across the unit were checked daily, with all necessary items present and in date. Equipment we checked such as defibrillators and suction machines had up to date electrical safety tests. We saw that the service maintained an up-to-date equipment log, ensuring devices were tracked and maintained, reducing the risk of equipment failure and supporting safe, continuous care for people.

The service did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

Data we reviewed showed staffing levels at St Helier Hospital were generally maintained to meet people’s needs, but there were ongoing challenges. Most shifts were filled, and the hospital used bank staff to cover gaps. However, reliance on temporary staffing remained high in some areas, particularly for ophthalmology medical staff and plastic surgery consultants. Inpatients cared for on the SACU were nursed by bank staff and supported by the clinic staff during the day. A high risk was noted on the service risk register regarding an inability for staff in the SACU to reliably deliver safe and compassionate care. This was due to conflicting demands from both a busy waiting room and inpatients, as well as the added challenge of uncovered bank shifts caused by competing pressures across the site for more staff. Vacancy rates were also above the trust target in some wards, including Mary Moore Ward and the SACU. Recruitment plans were in place, including proposals to appoint Advanced Clinical Practitioners (ACPs) and Advanced Nurse Practitioners (ANPs) in ENT, ophthalmology, and general surgery to reduce reliance on agency staff and improve continuity of care. Staff told us they felt there was generally stable staffing levels, with the service having enough medical, nursing and support staff with the right qualifications, skills, and experience to provide safe care. Nursing staff told us they could access medical staff when needed. Staff felt workloads were manageable and said they could escalate concerns when needed.

Leaders monitored staffing levels and used flexible approaches to maintain safety, such as redeploying staff during busy periods. However, shortages in occupational therapy and physiotherapist staff were noted, which staff told us affected timely rehabilitation for some patients. Some staff told us that staffing levels in recovery were particularly low at weekends and overnight, which they felt created risks for patient safety and could leave staff feeling vulnerable when managing emergencies or challenging situations. One staff member explained that during night shifts, there was sometimes only one recovery nurse on duty, which meant they could not always summon help quickly if needed. Following the inspection the trust informed us that it was standard that only one nurse was on duty in recovery, and that they were supported by the theatre team on call and situated in the adjoining room.

During our inspection we saw there were appropriate staffing levels and skill mix allocated to theatres, recovery, and the surgical wards, and recent recruitment had reduced vacancies. Staff described good teamwork and visible leadership. Staff received training appropriate to their role. New staff including bank and agency staff received an induction. Staff also completed mandatory training, the divisions overall compliance for medical and dental staff was below the trust target of 85% at 80.9% and among all other staff groups exceeded the trust target of 85% at 91.4%. Manual Handling Level 2 compliance among medical and dental staff was only 50.5%, and compliance with basic life support training fell short of the target at 77.3%. Resuscitation training demonstrated comparatively low compliance rates, with basic life support completed by 53.8% of additional clinical services staff and adult Immediate Life Support achieved by 71.1% of nursing staff. However, BLS and ILS modules for resuscitation were undertaken in alternating years, which may have influenced the reported data. Without specific timelines to address non-compliance there was limited assurance that improvements would be made.

Training and development opportunities were available, and staff felt supported to maintain competence. Leaders encouraged continuous professional development and provided access to specialist training where required. Staff described plans to implement training aimed at assisting nursing staff in encouraging early patient mobilisation, with the goal of enhancing outcomes for patients.

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.

The premises and equipment within the service were generally kept clean and hygienic. Clinical areas were observed to be clean, with staff utilising green 'I am clean' stickers to indicate which equipment had been cleaned that day. Staff were seen cleaning equipment after patient use, demonstrating adherence to some infection control principles. Theatre areas were visibly clean, although some were cluttered. There was access to hand sanitisers throughout the hospital and good hand hygiene was promoted. Staff audits consistently demonstrated good hand hygiene compliance across the division.

There was easy access to personal protective equipment (PPE) such as gloves and aprons. Staff followed IPC principles and were bare below the elbow. We observed theatre staff wearing appropriate PPE in theatres. If a patient was infectious, a sign was put on the door of their room to indicate this to staff and visitors. The service had systems in place to prevent surgical site infections, and staff worked to identify and manage these infections effectively when they occurred. Staff demonstrated good awareness of their responsibilities.

Waste management was handled in line with national standards, with different colour coding for general waste and clinical waste. All clinical bins were seen to be operated with pedal lids and were not overfilled. We saw that sharps were managed safely in line with national guidance, with correct disposal and secure containers in place.

The trust had an up-to-date policy for the Prevention and Management of Surgical Site Infections. The service monitored numbers of healthcare associated infections and surgical site infections (SSI). In the 12 months prior to the inspection, the service reported 11 healthcare associated infections. During the surveillance period October–December 2024, the trust recorded a surgical site infection (SSI) rate of 0% for large bowel surgery, representing a marked reduction from 10% in the previous year and performing well below the national benchmark.

The trust had an up-to-date Introduction to Infection Prevention and Control policy. The policy was comprehensive, and staff could easily access it. Staff had support from the site IPC team with a weekend service from IPC nurses and an out of hour’s service via the on-call Consultant Medical Microbiologist. This ensured that infection prevention and control concerns could always be addressed promptly, reducing the risk of infection transmission and promoting a safer environment for both patients and staff.

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 were stored securely, and access was limited to authorised staff. Controlled drugs were managed in line with policy, and fridge temperatures were monitored. Staff received training in medicines management, and their competency was regularly assessed. Staff demonstrated awareness of safe prescribing and administration practices. Pharmacy staff were readily available in hours and out of hours. Pharmacy teams provided clinical input, including medicines reconciliation within 24 hours and support for discharge medicines (TTOs), although capacity issues meant they were unable to attend ward rounds and multidisciplinary meetings. The absence of pharmacy staff at ward rounds and multidisciplinary meetings could limit opportunities for real-time input into complex medication decisions and collaborative care planning.

Patients told us they received information about newly prescribed medicines and were given the opportunity to ask questions about them. Patients we spoke with told us their pain had been managed appropriately, and they generally received pain relief in a timely manner. We also saw evidence of pain score tools being used. We saw in records that where patients had been prescribed and administered pain relief, this had been recorded accurately. Nurses carried out medication counselling and sought pharmacy advice when needed. Staff used electronic systems for prescribing and risk assessments, including VTE, and there were processes for off-label requests through the formulary team.

Staff were encouraged to report medicine related incidents and learning from incidents was disseminated across the service. Staff could give examples of learning from medication incidents which had led to learning and changes in practice. For example, staff told us about an incident involving the medication methotrexate which had led to changes in documentation to prevent recurrence. Leaders monitored medicines management and audits indicated compliance in surgical wards, with learning shared via huddles and team meetings.

People with allergies were clearly identified by a red wristband as well as electronic alerts. This helped staff to check and confirm allergies before prescribing or administering medicines, reducing the risk of harm and supporting safer care.

Antimicrobial stewardship was embedded across the hospital, with daily reviews and weekly ward rounds leading to interventions such as stopping unnecessary prescriptions, switching from intravenous to oral antibiotics, and aligning treatment with trust guidelines. Compliance with antimicrobial guidelines was high (90%), and the introduction of a new electronic prescribing systems helped reduce prolonged courses and supported timely IV-to-oral switches. These measures improved safety, reduced inappropriate antibiotic use, and promoted best practice in medicines management.

There was a high risk recorded on the service risk register regarding the storage and access of medications in theatres when cupboard doors were left open during surgical procedures for rapid access. Control measures were in place to reduce the risks associated with this, such as ensuring only non-controlled medications required for immediate use may be accessed with doors open and cupboards should be labelled with contents and expiry dates maintained.