West End Donor 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

The service had a good learning culture. Managers investigated incidents thoroughly. People were protected and kept safe. Staff understood and managed risks. The facilities and equipment met the needs of people, were clean and well-maintained and any risks were mitigated. There were enough staff with the right skills, qualifications and experience. Managers made sure staff received training and regular appraisals to maintain high quality care.

Find out what we look at when we assess this area in our information about our new Single assessment framework.

There was a culture of safety. The service learnt and improved from risks and concerns. There were structured channels to communicate risk and concerns. A daily team brief was held every morning, led by nurses and supervisors. A set format was followed and included discussions regarding concerns and notable information from the previous day, messages noted in the diary or daybook for follow up , appointments, staffing and skill mix. There was an organisation wide weekly team brief attended by managers and supervisors for cascading messages and information to local teams and a monthly update from senior managers, open to all staff.

Staff were encouraged and supported to raise concerns. Staff told us there were clear reporting lines available to them for escalating risks or safety concerns to their supervisor or with managers of the service. We were told that if there was a safety concern they felt comfortable bringing it to any manager and that both donor-carer supervisors and managers wanted to know about risks. Staff told us there was always an on-call manager available when none were physically present on-site.

Incidents and complaints were investigated, and outcomes were shared with staff. Learning from incidents and complaints resulted in improvement. Incidents were recorded and reported on through an online reporting system. A standard operating procedure defined the incident reporting and investigation process, which included a national quality assurance team reviewing and grading each incident. Incidents were allocated for investigation through root cause analysis and quality incident frameworks. Team briefs and team training days included cascading information of concern and lessons learnt. There were four team training days and two half days per year. There was also team time every month for an hour meeting. Staff were aware of the reporting tools in use at the service and felt able to use them. Staff demonstrated both were easy to access from the Intranet. Managers told us staff were encouraged to complete incident forms, and we observed posters encouraging staff to complete online incident reports.

The service promoted resolving any concerns or questions from donors in real time. Donors told us that staff were helpful in responding to any queries or concerns they had. There was a national complaints team who were contactable online or by telephone. Leaflets and posters were on display about how to access the complaints process, which was also located on the service’s website. Complaints were allocated to managers who would delegate this task to senior team members who made contact by telephone and email to seek resolution.

There were 2 freedom to speak up guardians (FTSUG) in the London area. 1 was a dedicated full-time officer who undertook this alongside their health, safety and wellbeing responsibilities for the organisation. The second FTSUG undertook the role as a special interest alongside their normal duties. The area manager also carried out problem solving and would speak to line management nurses.

A staff survey was carried out in December 2025, that included several questions. Goal setting, meaningful work and peer relationships all scored highly with 75%, 78% and 75% satisfaction rates. Reward, workload and transformation and change had the lowest staff satisfaction rates at 13%, 28% and 14%. Wellbeing and management support were 35% and 40%. All scores were below the national average. Survey results were raised in team meetings in order to prioritise actions based on themes identified in the survey. Managers told us that main themes were agreed as a team and included wellbeing, supporting teams, workloads and reward.

The judgement for Safe systems, pathways and transitions is based on the latest evidence we assessed for the Safe key question.

There were effective systems and practices to protect people from abuse and neglect. There was a national safeguarding lead for the organisation and standard operating procedures for the management and escalation of safeguarding concerns. The policy had been recently reviewed and donors were no longer permitted to bring their children into the building because staff could not guarantee the safeguarding of a lone child while the adult was donating. Donors had to meet the criteria to be able to donate. For example, donors had to be over the age of 17 years.

Staff understood, within the context of their own client group, what constituted a concern and how to take appropriate action. Staff we spoke with were aware of what constituted potential safeguarding concerns and how to escalate these. Staff were able to give examples of how safeguarding concerns had been identified and escalated for action from a range of different situations. The service had a 97% compliance rate for level 2 safeguarding training which was above the target of 95%.

There were a range of standard operating procedures (SOP) to manage risks. For example, the SOP for donor registration and pre donation screening, updated in October 2025 to reflect best practice. The SOP showed the processes to follow to ensure donors were formally screened according to donor selection guidelines and in accordance with the EU regulatory requirements.

Risks were assessed using an appropriate risk assessment tool. For example, all first-time donors, had a comprehensive health assessment carried out and were given an information booklet to read. The individual’s understanding of the donation process was reviewed with a member of staff prior to them giving blood. This review included identification of risk factors and the information provided was signed in front of staff on the day, to demonstrate accurate completion. Checks prior to donation included an identity check on the day and staff using the prompts in the donor criteria booklet to clarify eligibility. Iron levels were also checked before every donation. Based on these reviews people were then accepted or deferred.

For regular donors a second assessment form was used which was not as comprehensive. If a donor lapsed over two years, they would be re-assessed using the comprehensive form used for new donors. Regular donors were always asked about any changes of circumstance since their last donation and last assessment.

Post donation, donors were observed in the recovery area where they were given drinks and snacks. Recovery staff told us that everyone underwent a period of observation following donation. Staff told us that donors remained in the recovery area for a period depending on observations, donor feedback and assessment. We observed an accompanied donor enter the recovery space; recovery staff were made aware they were a new donor.

There was a clear process to check the prospective donor’s identity including name, date of birth, and address at the front desk upon check in. These identity checks were repeated during the consultation with a donor-carer in the consultation area, and again once the donor had been seated on one of the donor chairs. We observed donors being asked about travel and allergy information which was cross referenced with the ‘donor care book’, a large folder that included policies and guidance, and guidelines on approved medications. We also observed donor carers referring to previous individual donor assessment information and donor hydration. The screening process prior to donation included a finger prick sample, testing and assessment to determine continuation with donation or deferment to a further process of testing.

Individualised printed barcodes were stuck to blood bags to identify them as belonging to individual donors. The donor carer completed the donation record at each stage of the donation process. This information included which arm was used and which member of staff undertook which duties.

Staff were able to describe the assessment and escalation processes for deteriorating patients which included calling 999 if the donor wasn’t recovering over a period of time. There was a ‘feeling faint’ standard operating procedure and equipment such as blood pressure monitors were available to assess and monitor patients. Staff told us they were trained to identify and respond to signs of deterioration, such as pallor or light-headedness. Staff were also trained in basic life support. If any sign of deterioration was identified the donation was stopped immediately, the donor reclined back in the chair with snacks and water offered where possible. Notes were added to the patient record to ensure that staff were aware of previous deterioration at the next donation.

There were always trained first aiders on duty and nursing staff told us they attended all reports of unwell patients. If a donor fainted or became unwell but did not need to be transferred to the local emergency department, once they had recovered staff ensured the donor was picked up by a friend or relative and staff would call them the following day to check on their health.

There was a call line available to donors 24 hours a day, 7 days a week that donors could contact if they had any concerns post donation. All donors were sent home with a ‘feeling faint’ information leaflet which included advice and contact details if a donor was concerned.

The standard operating procedure (SOP) for Managing and Reporting Donor Adverse Events had been updated in January 2026 to reflect best practice. The policy documented the action that staff should take for several adverse events. These events included donors feeling faint or fainting, delayed vasovagal event, bruising or swelling, arterial puncture, arm pain, rebleed, allergic reaction and air embolism. Staff could easily identify the changes made to the SOP as these were clearly stated at the beginning of the document with reference points to the specific pages.

Environments were safe and designed to meet people’s needs. The service was located over 2 floors: ground and first floor. Reception was located close to the point of entry to the building. Floors were organised in to waiting area, donation area and recovery area. The premises were visibly clean, in a good sate of repair and well laid out. Spaces were uncluttered and organised despite its busy and well stocked environment.

Chairs in the waiting and recovery areas were comfortable and in good condition and the atmosphere was relaxed. Where people donated blood, chairs were specifically designed for blood donation. Donor chairs were able to recline as required and donors appeared to be comfortable sitting on them, with head pads and left or right armrest options for platelet donation.The chairs were visibly clean and without any physical defects. Chairs for donors were directly overseen by a nursing station.

Recovery areas were separated from the waiting area with different coloured seats and a recliner chair for donors who felt faint following donation. There were snacks and drinks available in the recovery areas.

Facilities, equipment and technology were well-maintained. There were effective arrangements to monitor the safety and upkeep of equipment and the premises. Calibrated beds were checked annually and recorded on a digital quality management database, which also contained prompts when attention was needed. There was a national team who attended to all servicing and monitoring. We saw the asset register which was updated to 5 February 2026. It demonstrated that calibration, maintenance and ad hoc repair for all items of equipment for the service was taking place. It demonstrated that all equipment used during blood donations and blood pressure monitors were being maintained in good working order.

Equipment was suitable for its intended purpose and stored securely. Staff showed us the venepuncture process and talked us through the steps including the use of equipment and decontamination procedure. Tubing was arranged through machines that monitored, mixed and weighed blood as it was collected. Staff kept a check to ensure an adequate flow of blood and responded promptly to alerts when the collection bags were full.

The temperature in the service was monitored several times a day, using a temperature checklist, Records demonstrated this had been fully completed on a daily basis. Staff told us that target temperatures were 15-25 degrees due to the required temperature requirements for the blood tubing. This was also stated in the standard operating procedure on temperature. We noted multiple readings for one day in January at 13 and 14°C. Managers told us this was due to a heating defect which resulted in the first-floor clinic not opening that day.

Once collected, blood products were stored in red bags in a restricted designated area. Blood products were collected on a twice daily basis and a blood collection timetable confirmed this was happening. Any underweight or unusable blood products were also collected and disposed of offsite. Therefore no blood products stayed on-site overnight or were disposed of in any other way.

Emergency equipment was available on site. An automatic external defibrillator and what staff termed a ‘re-bleed box’ consisting of gauze and bandages were mounted on the wall and were easily accessible. The service was in line with national guidance and was not required to have a resuscitation trolley or oxygen. Staff were trained to provide basic life support and the service’s policy was to call 999 in the event of an emergency. Staff we spoke with were aware of the location of the automatic external defibrillator (AED) in the event of a cardiac arrest and the ‘re-bleed box’, to be used in the event of continued bleeding after venepuncture. Staff told us they were trained to bring this with them in the case of an evacuation from the building so that donors could continue to be tended to outside.

Consumable medical products were easily accessible to staff. All of the items we reviewed, including multiple packs of blood tubes, bandages and gauze were in-date and visibly clean. Managers told us it was the service’s policy that staff could choose whether to use gloves and were only required to wear an apron if there were concerns about vomiting.

We observed clinical waste was handled in line with the provider’s policy and separated from general waste and collected daily. Staff disposed of used PPE appropriately in clinical waste bins. We observed staff disposing of used needles in sharps boxes, which were located at each consultation area and other appropriate locations. They were observed as closed when not in use and not over full. Sharps boxes were collected twice a daily which meant there were no used or full sharps bins on site.

Staff were suitably experienced, competent to carry out their role. There were appropriate staffing levels and skill mix to meet people’s needs. The service was open 7 days a week and each shift worked to an identified number of nurse managers, experienced nurses and donor-carer staff. There were separate teams on each of the 2 floors. Numbers and skill mix was calculated based on how many bookings and donor beds were in use each day. Managers were committed to organising staffing rotas at least a month in advance of shifts and told us they tried to give staff longer notice when able to do so. Daily team briefs reviewed staffing needs against the number of bookings. Staff told us there were not always enough staff which meant staff were sometimes tired or stressed. However, they did not think this had meant a greater number of needlestick injuries. We were told managers would sometimes support clinics when they were short of staff.

The service had high retention rates with only 1 member of staff having left the service in the last year. Managers attributed this to supporting alternative working practices. This included staff working fewer but longer shifts. Managers told us staff were in favour of this because it gave them a better home/work life balance. We were also told the organisation supported nursing staff with revalidation to retain their registration, supported overseas nursing staff to obtain UK registration and supported band 4 staff access nursing qualifications. However, it was acknowledged that this was now more difficult because of the processes involved.

Staff received training appropriate and relevant to their role. Staff participated in supervision, appraisal and were supported to develop and achieve professional revalidation where needed. A training matrix showed the national organisation’s expectation and aligned job roles to specific training to ensure people had the right skills. There was a 97% compliance rate for mandatory training. Annual appraisals were known as a personal development and performance review (PDPR) and 100% of staff had had a PDPR. Staff also participated in 6-month reviews and check-ins between reviews. Staff told us they felt supported by managers and that they received training to enable them to do their job and progress their careers. They told us they had annual appraisals which included wellbeing check-ups and a discussion about career progression.

The organisation had a corporate nursing development team who supported induction and ongoing training alongside trainer-facilitators based at the service. This included professional development nurses, clinical skills trainers and professional nurse advocates. There was an 8-week induction period for qualified nurses and a 6-week process for donor-carer staff. Induction included shadowing practice and specific competency workbooks for both nurses and donor carer staff. Both the nurse and donor-carer induction and training packs we reviewed showed there was a structured induction and training programmes for both staff groups. The inductions included workbooks, progress check ins, checklists and consolidations.

Premises and equipment were visibly clean. All areas of the service we observed were clean and dust free on high and low surfaces. Cleaning records were completed and signed for every day. They demonstrated that daily, weekly and monthly cleaning tasks were taking place. There was good interaction between staff and cleaning staff. Countertops, workstations, donor chairs, cupboards and consultation areas were visibly clean and free of grime and dust. We observed donor carers wiping down beds after use with sanitising anti-bacterialwipes. Beds were cleaned each morning with soap and water. It was also standard practice to wipe blood pressure cuffs and used tables with sanitising anti-bacterialwipes in between use.

Hand gels were available in all areas and routinely used by staff. All staff were bare below the elbows. We observed staff using alcohol gel between touching donors and before and after inserting needles. There were hand washing guide posters and a cleaning summary statement on display, visible to all centre users. This included a mission statement to donors about a commitment to cleanliness.

The risk of infection was effectively assessed and managed in line with current relevant national guidance. There was a national lead for infection prevention and control (IPC) and local IPC champions. There were standard operating procedures for infection control protocols for blood donation and screening. The service lead for IPC completed audits which were reported into the national lead and actions reviewed in team training days and team briefs.

The judgement for Medicines optimisation is based on the latest evidence we assessed for the Safe key question.