The London Welbeck Hospital

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last inspection we rated this key question requires improvement. At this inspection, the rating has remained requires improvement. This meant people were not safe and were at risk of avoidable harm. We assessed five quality statements. The service was previously in breach of the legal regulation in relation to safe care and treatment. Improvements were not found at this assessment, and the service remained in breach of various other areas of this regulation. Medicines in theatres were not always managed in line with best practice, placing patients at risk of harm. Staff did not always follow best practice guidelines for record keeping. Therefore, accurate and up to date records may not be maintained. Staff did not always adopt measures to prevent the control and spread of infections. This could increase the risk of the spread of infection and cross contamination. However, staff assessed risks and made sure patients understood the risks associated with their care. On the ward, staff dispensed and administered medicines safely and effectively to patients, to support their recovery from surgery.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Patients told us they were advised to raise any queries at consultation with the consultant or other suitably qualified clinical staff. Those who raised queries reported they were provided with a full explanation. We observed there was information available at the service on how a patient could make a complaint or raise a concern. We were told that patients and their families were involved in investigations if they wanted to be. They were given an apology and an explanation of the event.

Staff were confident to report incidents, they knew what they should report, when and how. They felt supported when things went wrong and were encouraged to communicate issues directly to management, either via email or in person. Following our assessment, the provider told us they had published a service level Freedom to Speak Up policy, which will enable staff to freely speak up about any concerns and to encourage a culture of openness and accountability. However, as this was not in place at the time of our site visit, we were unable to assess its effectiveness and if staff were aware of this policy.

The service did not always ensure compliance with the World Health Organisation (WHO) five steps to surgical safety checklist. The two operations we observed during our assessment found that the WHO surgical safety checklists were not completed in accordance with best practice. We noted not all staff were engaged or interacted with the safety checks before the operation commenced and once the operation had concluded. The lack of an effective approach to these safety checks placed service users at risk of harm. Following our assessment, the service told us that they have provided in-house training for theatre staff that emphasised importance of compliance with the WHO surgical safety checklist. Staff have also been reminded that this must be completed for all surgical procedures. However, as this training had not been completed at the time of our site visit, we were unable to assess its effectiveness and if compliance with the WHO checklist had improved and been maintained. We spoke with patients following our site visit, who felt staff prioritised their safety. Patients told us they felt their referral, admission and discharge from the hospital was “smooth.” Patients were kept informed about the details of their care and knew who to contact following their discharge should they have concerns or queries and were provided with a helpline number that was available 24 hours a day, 7 days a week.

At the time of our site visit, the service did not undertake observational audits of staff compliance with the completion of the WHO Surgical Safety Checklist. The lack of observational audits meant any improvements in staff practice would not be identified and action taken, placing service users in theatres at risk of harm as the WHO surgical safety checklist may not have been completed in line with best practice. However, the service had systems in place to support the care and treatment of patients to and within the hospital. The service carried out pre-admission assessments in line with national guidance. These included a risk assessment of the patient’s suitability for the procedure, such as their medical history, general health, age, medications and other planned procedures. The service identified psychologically vulnerable patients and referred them for appropriate psychological assessments. All staff we spoke with were familiar with the escalation protocols for deteriorating patients and the use of national early warning scores (NEWS2). Staff understood the process for managing medical emergencies and the service had resuscitation equipment available if required. Staff told us that, where the hospital did not have the facilities to care for a deteriorating patient, patients would be stabilised and transferred to a local NHS hospital via ambulance in the first instance. The hospital also had a service level agreement in place with a nearby independent hospital for the transfer of patients requiring critical care.

n/a (we did not assess this evidence category during our assessment).

The service did not always ensure compliance with the World Health Organisation (WHO) five steps to surgical safety checklist. We observed poor compliance with adherence to several policies and procedures. For example, lack of compliance with checking and recording swabs and instruments counts. Staff failed to follow best practice in relation to record keeping. We observed staff completing records to document all elements of the WHO five steps to surgical safety checklist had been completed, when in fact staff had not completed the required checks. This failure to follow best practice placed patients at risk of harm and was a breach of the professional’s code of conduct. However, the service had processes in place for clinical assessments. There were processes for management of deteriorating patients and medical emergencies. We saw that patients were given written aftercare instructions, before being discharged. This ensured that patients were clear about any next steps required following surgery.

Patients told us staff provided them with comprehensive information when discussing potential risks related to their care. Staff completed patient assessments and provided an explanation of risks. Staff always respected patients’ choices and preferences.

Staff informed us that they carried out risk assessments for patients preadmission. Staff reviewed the risk assessments with the patient, which enabled appropriate provisions to be identified and put in place. Staff had access to translation services for patients whose first language was not English. Staff could confidently explain how they keep people informed about any risks, such as venous thromboembolism (VTE) and the advice regarding management of risks. Staff were able to describe the advice they provide to patients regarding signs and symptoms of clots prior to their discharge. Staff felt they had the appropriate training to understand and manage the risks associated with patient care, whilst protecting their rights and dignity. This included training in the management of sepsis, medicines and intravenous administration. Staff had also completed appropriate basic life support or immediate life support training. However, during our site visit, we noted that some staff did not always manage medicines in with best practice. Staff explained how risks were managed in emergency situations and the process for escalation. Staff knew how to provide emotional support and told us patients had their mental and emotional health assessed during their initial consultation and if necessary, would be offered counselling prior to surgery.

The service had policies in place to improve care, for example the recognition and management of sepsis and improving outcomes for patients with sepsis. The service carried out risk assessments for patients, and these were communicated with the team effectively and documented in patient care records. The service used a recognised classification system to grade a patient’s level of risk for undergoing surgery. The service only accepted referrals from patients who were classified as low risk as they were generally fit and healthy and low risk of developing complications during or after surgical treatment. If a patient deteriorated, nursing staff told us they would seek support from the resident medical officer (RMO) and inform the hospital clinical manager. The RMO would contact the patient’s consultant and make arrangements to transfer in the first instance to a local NHS hospital, depending on the severity of the patient. There were appropriate processes in place to support patients at discharge through discussion and written information. Patients were discharged once they had recovered appropriately from their procedure and anaesthesia. This included ensuring their vital signs were within normal limits, they were alert and orientated, had eaten and drunk and were not suffering from nausea.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe and effective staffing during this assessment. The score for this quality statement is based on the previous rating for Safe.

Patients were supported to receive their prescribed medicines in a way that met their individual needs. Patients received guidance and training to understand how to support themselves with their medicines on discharge from the service. For example, some patients were prescribed injectable medicines to reduce the risks of clots following surgery. Nurses provided patients with training on how to use these medicines on discharge, as well as providing a sharps bin that could be used to safely dispose of needles following injection. There was a separate information leaflet given to patients to support with the use of these medicines on discharge. Patients had access to knowledgeable staff who were able to answer any questions about their care and treatment with medicines. They were able to contact the ward after discharge for support if needed.

Staff were suitably trained and assessed as competent to administer medicines. The service used a paper prescribing and administration record. The service’s resident medical officers (RMOs) supported medicine management by the prescribing and dispensing medicines for patients, ensuring they were available in a timely manner. However, we observed during our assessment that the training to administer medicines was not always implemented in practice. Staff had regular ward meetings between nursing staff and health care assistants, where they would discuss practice and share learning.

Medicines were not always stored safely and securely in theatres. We saw that medicines cabinets including the controlled drugs cabinets were left open and unattended in theatres when surgeries were not being conducted. This meant unauthorised personnel could access these medicines and was not in line with best practice. In theatres, medicines were being stored in a domestic fridge rather than a temperature-controlled medicines fridge. This meant the medicines may not have been stored at the manufactures recommended temperature, which could impact on their effectiveness as domestic fridges do not maintain a uniform temperature. We saw a syringe labelled as containing morphine was unattended on a surgical tray in one theatre. When raised with staff we were told that this syringe contained saline and not morphine. This practice of using labelled syringe for alternative medicines is not in line with best practice and placed patients at risk of receiving incorrect medicines. We could not therefore be assured medicines were stored at the recommended temperature to ensure they were effective and fit for use. However, we saw medicines were stored safely and securely on the ward.

We observed that medicines in theatres were not always stored and managed in line with the service’s policies and procedures, and the policies in theatre were not always followed. During our assessment, medicines were being stored in a domestic fridge rather than a temperature-controlled medicines fridge. Controlled drugs cabinets were left open and unattended when surgeries were not being conducted. However, a medicines audit of the ward environment was conducted annually by an external pharmacy company, and actions and learning from the audits were embedded into practice. For example, it was recommended that all entries on the controlled drugs register should have the responsible person and witness’s name printed and signed, rather than just initials. Medicines management incidents, including errors and near misses with medicines, were recorded and learning shared with relevant staff to prevent future recurrence. The service also undertook monthly internal medicines audits of the wards, where no concerns were identified. The service had medicines policies in place which were in date, reviewed regularly and covered a range of areas, for example a policy on the storage and supply of medical gases and antibiotic guidelines. However, these were not effective as they did not identify the failures and areas for improvement identified during our assessment.