Blackpool Victoria 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 assessment we rated this key question inadequate. At this assessment the rating has changed to good.

Most aspects of the service were safe, and there was assurance regarding a positive learning culture, patient pathways, safeguarding practice and managing risk.

Staff recognised and reported incidents and near misses. Managers investigated incidents and shared lessons learned with the whole team and the wider service fostering a learning culture. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Medicines management was safe and met people’s needs, capacities and preferences. 

However, we identified three breaches of the regulations relating to premises and equipment, not all staff had undertaken the required level of mandatory training and staff did not always comply with good infection prevention and control practices relating to the use of personal, protective equipment.

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 evidence showed a good standard. 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 learned to continually identify and embed good practice.

Patients were positive about their experience and interactions with staff. They told us they felt confident and comfortable to raise concerns, although none of the patients we spoke with had needed to raise concerns during their stay.

All staff we spoke with could articulate how they would raise incidents and were encouraged to do so by senior leaders. All staff knew what constituted an incident and could give examples of incidents that they had raised. Incidents were investigated by senior leaders within the medical care division using nationally recognised tools such as “After Action Reviews” (AAR, a structured, blameless evaluation method used to analyse the success or failure of a project, event, or task) and Patient Safety Incident Investigation proformas.

Managers informed us they shared lessons learned from incidents or complaints through alerts, daily safety huddles, handovers and team meetings. Staff provided multiple examples of when improvements had been made following learning from patient safety events and shared their awareness of the information and learning that was available on large white notice boards on each ward visited.

Trust data showed that there had been 3 never events and from June 2025 to December 2025 the trust had commissioned investigations into 9 incidents.

For the same reporting period, 429 patients experienced a slip, trip, fall or collapse, and 450 patients experienced pressure damage attributed to the medical wards.

Staff understood the duty of candour, and an up-to-date duty of candour policy was in place. Since June 2025, there had been 29 incidents that required duty of candour, where staff contacted patients and their representatives to apologise when care and treatment did not go to plan.

Staff told us that they were debriefed and received support after a serious incident.

We saw examples of incidents with lessons learned and action taken because of investigations.

There was a governance process in place where complaints, incidents and risks were reviewed.

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, monitored, and assured. They made sure there was continuity of care, including when people moved between different services.

Patients we spoke to told us they knew what was happening in relation to their care and treatment, and what was happening next. Patients we spoke to had been involved in discharge planning.

The trust had a standard operating procedure for admitting patients, which included strict exclusion criteria to ensure only appropriate patients were admitted, as well as the maximum number of additional patients a ward could safely care for. Staff reported these criteria were adhered to.

We observed the stroke wards being supported by the physiotherapy team who were based on the ward with a physiotherapy room, a rehabilitation area, and a breakfast club.

We observed patient files with referral and admission processes completed, which ensured that all essential information about the patient was received to determine if the patient’s needs could safely be met. We observed effective board round meetings and discharge meetings, staff demonstrated good working links with external partners and community initiatives.

Staff involved all the necessary health and social care services to ensure patients had continuity of safe care, both within the service and post-discharge.

The transfer of care team described how the transfer of care from hospital to social care partners was managed, including their involvement in the daily board round meetings. They described pathway arrangements, including on-site social workers (where available), complex nursing assessments, and support from the learning disabilities team and community nursing teams, working in partnership through to discharge.

The evidence showed a good standard. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They 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.

All staff we spoke with were able to describe and explain how to recognise and report safeguarding concerns. The trust had a safeguarding team in place, and staff knew how to contact them for advice and support. Safeguarding referrals were completed appropriately, and potential safeguarding concerns were discussed during the daily ward board rounds.

Trust-wide data showed staff training compliance for children and adult safeguarding was above the trust’s expected target of 85%. However, the children’s safeguarding training level 3 compliance for doctors was 68%, which was below the trust’s expected standard and targeted work was in place to address compliance.

Training compliance for learning disabilities, autism and neurodiversity training was 98%; dementia training 96%; Mental Capacity Act and conflict resolution 95%.

Safeguarding policies for children and adults were both recently reviewed, in date and appeared appropriate.

Safeguarding operational meetings were in place which provided a forum for sharing information, reviewing processes, and discussing key events.

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.

Patients told us that staff communicated well with them and their families, ensuring they understood their care and treatment. Staff also used effective methods to support people with communication difficulties. For example, we saw posters advertising translation services for people whose first language was not English, as well as information about advocacy support. We also observed that communication passports were in place where needed. Records showed detailed notes of conversations held with patients and their family members.

All patients and families we spoke with told us they were involved in the decision making about their treatment. Patients and their families said the staff on the wards had been very helpful and explained things well. However, we did receive some feedback from patients that they did not feel included in conversations and decision making with their consultant.

Staff had access to policies and procedures to support them assessing risk of harm and deterioration of patient’s conditions. Treatment escalation plans were used by staff to record and communicate patient's personalised and realistic goals for treatment, particularly when their condition may deteriorate.

Staff completed risk assessments for each patient on admission using nationally recognised tools. This included a range of risk assessments, for example, mobility, falls, pressure areas, sepsis and nutrition. When actions or plans were required to reduce the level of risk, patient records showed these had been completed.

Staff used a nationally recognised tool to identify deteriorating patients and escalate their conditions to medical staff. The National Early Warning Score (NEWS2) was used to identify patients at risk of deterioration. Our review of documents showed staff completed scores correctly. When a concerning score was calculated, the patient was escalated for medical review. Staff demonstrated a good understanding about the use of NEWS2 and when and how to escalate a deteriorating patient to medical staff.

The trust target for Venous Thrombo-Embolism (VTE) assessment compliance is 90%. Patients were risk assessed on admission to hospital. Completed assessments were above the 90% trust target from April 2025 to October 2025. However, compliance with completing assessments within 14 hours of admission was below the target in each month across the same period.

Systems were in place for patients and their families, friends, or carers to escalate concerns about their conditions. The service had implemented ‘Martha’s Rule’ which enabled patients and those close to them to contact the team if they felt their condition was worsening and this was not being addressed by the ward staff. Posters advertising this service were visible on the wards.

Patients who required additional support were identified with picture cards next to their bed or outside the side rooms. Staff shared other teams they drew support from such as the Speech and Language Team (SaLT), tissue viability nurses and physiotherapy. We observed that staff were based within bays to provide regular observations and monitoring of risk such as falls. We saw evidence of falls alarms in place.

Ward managers told us of falls reduction initiatives and a rapid improvement programme that has been in place over 12 months which had seen a reduction in falls on wards. Trust data that was reviewed monthly had evidenced improvements and a reduction in patient falls since the start of the rapid improvement programme.

Patients who were at risk of health care associated pressure ulcers, reporting information was collated on a monthly basis with a quarterly reporting process, data reported in October 2025 showed the monthly pressure ulcer audit conducted evidenced divisional compliance with 95% compliance in July and August and 96% in September which showed an improvement and a decrease of pressure ulcer reports from the previous reporting quarter.

Managers were able to describe their top risks for their ward and division and clearly articulate the mitigating plans and improvement plans to address each of these risks through the Improving Fundamentals of Care workstreams. The highest rating risks identified were staffing, falls and health related pressure ulcers. This information was recorded and presented on quality improvement boards on the wards.

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.

Fire doors were found being held open with wedges and large bins. We immediately raised this with ward managers during our observations and the obstructions were removed. We also identified concerns with fire exit obstructions, the trust provided assurances that action had been taken and the obstructions were subsequently removed. Oxygen was not always stored safely and securely. Signs were missing from storage areas where oxygen was held. The trust provided assurance where signs had been produced, and the estates team were implementing these and ensuring safe storage across the trust. This was a breach of premises and equipment.

During our visit, we identified unlocked storage rooms on two wards, including general storage, sluice rooms and equipment rooms. On a third ward, we found the treatment room unlocked; however, all medicines were appropriately secured within locked cupboards. We shared these findings with the respective ward managers at the time of inspection.

Housekeeping staff had checklists, this was completed on the wards visited. However, we found housekeeping records to be inconsistent for Legionella checks, this was checked by the housekeeping team and kept additional handwritten notes on the checklist, other wards did not have this check in place on the form.

Ward managers confirmed health and safety checks for the environment were undertaken on a schedule and audit outcomes were shared on the wards and recorded on the internal ATLAS system.

The trust had an ongoing refurbishment plan, and we saw 1 ward had recently been refurbished to a high standard, resulting in a fresh, spacious and welcoming environment, the area required a new counter top in the clinic room, this was on the maintenance list and documented on environmental audits.

The service had enough suitable equipment to help them safely care for patients. We reviewed a sample of equipment such as defibrillators, suction machines and blood pressure monitors which had stickers to indicate that they had been serviced within the last 12 months. We checked the resus trolleys on wards and found them to be checked daily by staff. Staff completed daily safety checks of specialist equipment and evidenced on the system where the checks were recorded.

Staff had access to equipment and consumables they needed; however, we found some expired consumables which the trust took action over and checked all stock on all wards and expired stock was removed with a ward checklist introduced to strengthen existing processes.

The evidence showed some shortfalls. 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.

Staff had received and were up to date with appropriate mandatory training. Staff received training in conflict resolution; equality and diversity; fire safety; health and safety; infection prevention and control; information governance; moving and handling; learning disability and autism and safeguarding children and adults. However, there were various levels of life support specific for adults and children for their role and the overall compliance was 80% which is below the trust compliance target. This is a breach of staffing.

Many staff gave mixed feedback on their annual appraisal completion. The trust highlighted a recent reduction in appraisal compliance figures reported to the Workforce Assurance Committee in October 2025 with an improvement plan trajectory to be in line with trust targets by March 2026. Appraisal compliance for acute medicine was 58%; care of the elderly persons and frailty 88%; general medicine 64%; operational management 47%; respiratory 78% and stroke areas 68%. This is a breach of Regulation 18 Staffing.

The service planned and regularly reviewed staffing levels and skill mix to ensure people received safe care and treatment. Leaders used staffing tools to ensure that there was enough staff to deliver care and treatment and staffing was reviewed yearly. Ward managers confirmed their involvement in staffing reviews.

Staffing ratios were clearly displayed on white boards on each ward, showing both the planned and actual staffing levels. Overall, wards had the planned number of staff on the days of our assessment, however on 1 ward, a member of staff was absent on the day of our visit. Managers acted appropriately when unanticipated absences occurred, transferring staff from other areas where necessary and we observed the handover of the patients to support the staff member which also included a ward orientation. When necessary, managers deployed agency and bank nursing staff to maintain safe staffing levels.

The trust had a robust tracking tool to oversee where recruitment was required for each department and specific role. Leaders told us they used regular bank and agency staff to fill the staffing gaps while recruitment was being undertaken. This was evidenced by a 90%+ shift fill rate meaning that the services were very rarely short staffed.

All staff we spoke with told us they enjoyed working at the service, some of the staff had been with the trust many years and others were relatively new to the wards. Trust wide data as of October 2025 showed low staff turnover rate of 11% which was below the trust target of 12%. The service had low sickness rates of 3% among medical staff, and 6% among nursing staff.

The trust had a process in place to ensure staff had relevant competencies checked and specialised training was also delivered across the trust which were also embedded in the induction process and an appropriate induction policy was in place.

The team included or had access to the full range of healthcare professional specialists required to meet the needs of patients. As well as doctors and nurses, specialisms such as occupational therapists; physiotherapists; social workers; tissue viability nurses; medicines management; speech and language therapists; respiratory nurses; end of life care; and dieticians.

However, we observed on one ward a housekeeper assisting a patient who was mobile, housekeepers were trained to level 1 moving and handling, the trust has reviewed manual handling for housekeepers and level 2 moving and handling training will be provided to housekeeping staff moving forward to ensure correct manual handling techniques are followed.

The evidence showed some shortfalls. The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading.

Patients who required isolation were placed in single rooms; however, staff did not consistently follow safe infection prevention and control practices. We observed 3 isolation room doors were left open, creating potential infection risks. We observed staff leaving isolation rooms in PPE (personal protective equipment) without performing hand hygiene, and others entering ward areas wearing the same PPE. Soiled linen was removed from isolation rooms without correct bagging. In addition, waste management was poor, with clinical waste found in domestic bins and pharmaceutical waste bins filled above the safe limit. This was a breach of safe care and treatment.

We observed commodes which were soiled with ‘I am clean’ stickers on them, and commodes that had not been cleaned after patient use.

We found catheter bags on a number of wards touching the floor without the use of stands to support them and keep them off the floor, this was addressed and action taken by the trust.

Treatment room cleaning and stock checks were not always undertaken as scheduled or not recorded as completed.

Privacy curtains on wards were not always dated when a change was required, we observed curtains dated which had not been changed since January 2025.

The trust monitored the infection prevention and control (IPC) through various means of tests, checks and audits to prevent hospital acquired infections.

We observed signage to show the risk of infections on wards to be confusing and inconsistent, some of the signs upon the main entry doors to wards were broken and the level of risk could not be ascertained. When speaking to staff the signage on the wards were not compatible with the level of risk.

Ward areas looked visibly clean, and we noted housekeeping and cleaning staff on all wards visited during the assessment.

Hand hygiene signage was displayed throughout wards. The trust regularly audited hand hygiene, waste management, linen management and ward environments.

Following feedback provided to the trust of the assessment observations, the trust informed us that action would be taken to improve adherence with infection prevention and control guidelines.

The evidence showed a good standard. 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.

We saw good, regular pharmacy support on the wards and positive pharmacy interventions being made relating to patients’ medicines. We saw evidence of effective communication of medicines issues between pharmacists and other healthcare professionals.

Ward staff knew how to obtain medicines that were not routinely stocked on wards as well as medicines out of hours.

Controlled drugs were handled safely across all wards.

Staff followed guidance to give medicines given via a syringe driver safely and regular checks were in place.

Risk assessments for venous thromboembolism (VTE) were completed promptly and medicines were prescribed appropriately.

We saw that high-risk medicines, including insulin and anticoagulants (medicines to help prevent blood clots), were prescribed and monitored correctly.

We saw that, in most instances, time-critical medicines were administered on time. Trust audits showed continuous improvement in the administration of time-critical medicines.

People’s allergies were recorded on the electronic prescribing system. For patients requiring oxygen therapy, oxygen was correctly prescribed on the electronic prescribing and medicines administration system.