Oaks 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

As part of our assessment of the safe key question, we reviewed the learning culture, safe environments, and safeguarding measures. Staff followed corporate policies and procedures to maintain patient safety, promptly reporting any concerns related to patient or environmental safety. Managers proactively addressed these issues to mitigate risks to both patients and staff.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Patients we spoke to on the day of the inspection told us they did not know how to make a complaint. However, patients felt confident that if they wanted to raise any concerns, they could speak to any of the members of staff on shift. We observed patients being treated with dignity and respect. Patients told us they felt supported and were kept well informed about their health. We were told staff provided relevant information about how patients could receive the mental, physical and emotional advice they needed. During our inspection we looked at completed patient feedback forms. Patients said “everything was explained really well” and “helpful, friendly and attentive staff”. Patients on the day said staff were flexible and communicated really well throughout their journey at the service.

Staff understood how to raise concerns and report incidents, describing feedback methods from leaders through huddles and team meetings, which also discussed patient handover arrangements. Staff and leaders reported using the Patient Safety Incident Response Framework (PSIRF) to investigate incidents, which has positively changed their approach to incident investigating. They demonstrated knowledge of accessing the incident reporting systems, knowing what to report and how to report it. Staff felt encouraged to report incidents and raise concerns. All staff described a positive, safe working environment with the freedom to speak up, emphasising an open and transparent culture. They understood the duty of candour and how to be open and transparent with patients if things didn’t go as planned. A strong culture of safety and learning was evident. Leaders indicated that the patient safety group met every Friday to discuss incidents from the previous week, including action points and learning outcomes. Managers shared this learning with staff during monthly team meetings, weekly stand-up meetings, and daily huddles. Information from the patient safety group was included in a clinical report displayed on staff notice boards. There was evidence of changes made as a result of feedback. Staff described audit days aligned with incidents and training on emergency scenarios during these days. Meeting minutes reviewed showed action points from previous meetings and discussions about recent incidents and actions taken. Staff described opportunities for progression through apprenticeships and role development. Unqualified staff were qualifying in healthcare roles, including the introduction of the resuscitation coordinator role, empowering staff to take on new responsibilities.

The service had processes in place to investigate incidents. Staff told us they reported incidents on the radar system which would notify the line manager and the senior leadership team. The service had several meetings in place to discuss learning from events that have put people at risk of harm. We saw examples of communication to staff to show organisational learning and actions. This included examples of internal flash reports being disseminated, the staff newsletter and the clinical quality report being disseminated to staff.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

Patients told us they had been fully informed about the procedure that they were having. One patient said “they were informed every step of the way”.

Medical and nursing staff received training specific for their role on how to recognise and report abuse. Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act. Staff described the escalation process within the team and the senior leadership team. Staff knew how to make a safeguarding referral and who to inform if they had concerns. Staff we spoke with knew who the safeguarding lead was and felt confident if they needed to inform them of a safeguarding concern. There was a safeguarding escalation process available in all areas. We saw safeguarding information in the staff room with details of how to raise a concern and where to access help and advice internally and externally.

Medical and Nursing staff we spoke with, all stated they had completed safeguarding e-learning and had been given time to do this. The service provided data regarding safeguarding training. Following the inspection the service provided safeguarding mandatory training statistics. Safeguarding adults level 1 training was 97%, adults level 2 training 95% and adults level 3 training 87% compliant. Safeguarding children level 1 and level 2 training was 97% and safeguarding level 3 training was 100% compliant. Staff had access to the service’s corporate safeguarding adults at risk of abuse or neglect policy. We also reviewed the corporate safeguarding of children and young people policy. We reviewed the policies, which were in date and in line with national guidelines. The policies described the escalation and reporting processes. Following the inspection we requested safeguarding audits. The service provided a copy of an audit which was completed after the inspection. The service did not provide any evidence of safeguarding audits completed prior to the inspection. The service told us there were two DBS checks outstanding for bank staff members. One DBS check was being processed and the second a renewal was in progress.

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

We spoke with a patient who gave us some positive feedback about their experience of care. Patients told us they felt safe and supported in the service. Patients said staff were attentive and answered call bells promptly.

Staff stated training was provided on equipment when required and when new equipment was introduced to the department. Staff described that they felt safe to deliver good patient care and had the equipment and training to do so. A robust process was in place for the cleaning, sterilisation and tracking of endoscopes cleaning process. A robust process was also in place for tracking/auditing the usage of endoscopes on patients.

Ward and theatre areas were clean with well-maintained furnishings. Staff demonstrated good infection prevention and control (IPC) practices, adhering to effective hand-washing guidelines. Visitors were required to sign in and out of a logbook, and all departments had secure access. Patients' rooms were clean, tidy, and many had ensuite bathrooms for privacy and dignity. Records showed that staff conducted daily, weekly, and monthly checks on specialist and emergency response equipment. Emergency resuscitation trolleys in recovery and on the ward were sealed with identification tags. However, in the equipment storage room, faulty equipment was not clearly separated, and labels were on the floor. We saw intravenous fluids were set up in the medical equipment storeroom. We asked staff about this and was advised it was for training. However, there were no labels or signs indicating this. Outdated cleaning audits from 2022 were found in the implant room, sterile storeroom, and sterile instrument room, but up-to-date records were provided following the inspection. The environment was generally clean, but the theatre area lacked sufficient storage facilities. The instrument storeroom was untidy and overstocked, blocking the fire door and making equipment access difficult. The senior leadership team acknowledged these issues, noting an action plan and recent storage equipment orders. Post-inspection, they provided the action plan which included information about new shelving and risk assessments, evidence of actions taken, and a standard operating procedure (SOP) for managing faulty equipment. The service had also introduced a faulty equipment logbook. Ward areas had well-organised, accessible storage facilities. Records were generally secure, but one storeroom contained disorganised folders with patient information. Staff removed these folders promptly after being informed during the inspection.

Equipment and technology were well-maintained and consistently supported staff to deliver safe and effective care. Electrical equipment had been regularly serviced and conformed to relevant safety standards. We saw the standard operating procedure (SOP) for the clinical and general waste disposal and the corporate waste disposal policy which were in date and ratified.

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.

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

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