Weymouth Hospital

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• 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 assessed 3 quality statements in the safe key question and found areas of good practice. The scores for these areas have been combined with scores based on the rating from the last inspection, which was good. Though the assessment of these areas showed good practice since the last inspection, our rating for the key question remains good. The service was safe. Staff trained to identify abuse and take appropriate action when adults were at risk of harm. The service had appropriate equipment in place to meet the needs of their patients safely.

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 provided feedback through a number of avenues. We saw that external websites used for reviews had been verified. A patient told us that they were a very nervous patient, but felt all the staff were good at calming their fears. The nurse walked them to the theatre arm-linked, and their husband was kept informed. At the change of shifts, nurses said bye and introduced the oncoming nurses. The patient said that they were looked after well and had a fantastic anaesthetist, who explained everything to them. The patient explained that a heart scan was arranged due to high blood pressure and that all staff were excellent. The patient said they were treated with respect and staff were discreet when taking the catheter out. There was a minor problem with the TV. But it was good to have their relative stay in the room. The service received was exceptional and the consultant even contacted them when they were abroad. The consultant surgeon was excellent and information was given to me directly by the surgeon.

The Resident Medical Officer (RMO) was able to describe the incident reporting framework used at the hospital. Posters informing staff of how to report an incident were on display throughout the hospital. Processes were embedded to ensure immediate learning and safety. Hot Debrief forms were available following an incident to discuss next steps, safety netting for patients and to provide staff support. Examples of when the form could be used included but was not limited to anaphylaxis, when 999 was called, a serious incident, cardiac arrest and a never event. The RMO had a full understanding of the duty of candour but there were no such incidents at the hospital where this duty needed to be exercised within the last 12 months. Patients were a part of the feedback processes and were asked to complete a patient satisfaction survey before they were discharged. Patients had the opportunity to escalate concerns or feedback directly to the director of operations. This feedback was presented at monthly ward meetings. Staff knew the escalation process for raising concerns. This included talking to their line manager, Human Resources (HR) or Caldicott Guardian to escalate concerns. The provider had Freedom to Speak Up (FTSU) information in the form of posters, which included the named FTSU for the hospital in line with guidance from NHS England. The hospital also had a FTSU policy which was due for review in October 2025. The policy listed several people to speak to including a Freedom to Speak Up Champion, senior management and HR officers.

The service managed patient safety incidents well. Managers investigated incidents and shared lessons learned with the whole team and the wider service. Learning included updates from regulatory bodies. There were no never events, laser, transfusion or safeguarding incidents reported between 1 January 2023 to 31 December 2023. In the same reporting period there was a total of 193 incidents. • 131 incidents were clinical incidents. • 62 were non clinical incidents. • 26 were near misses. • 4 were classed as serious incidents. • 38 were classed low harm. • 93 were classed no harm. We reviewed evidence of duty of candour training presented to staff of video call and had over 30 staff members in attendance, staff could review the training video and PowerPoint slides at a later date. The training made a clear reference to Duty of Candour Policy which was due for review in August 2025. Staff met in different forums to discuss feedback and look at improving patient care. For example, daily huddle meetings took place Monday to Friday to discuss patient handover arrangements, patients’ feedback of care and elective weekend cases. We were also shown evidence of numerous meeting minutes which discussed high level feedback and incidents. The four incidents classified as serious incidents were reviewed and investigated with input from the clinical governance chair. No themes were identified amongst the serious incidents.

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.

Where appropriate, nursing staff arranged telephone calls with patients post-discharge, to gather additional feedback from patients and for nursing staff to follow up with patients on any concerns they might have experienced during their stay. Patients said that staff took great care of them and made them feel completely at ease with everything. Patients told us that they were treated with dignity and respect. One patient said that a ‘’nurse walked me to the theatre arm-linked. At the change of shifts, nurses said bye and introduced the oncoming nurses. I was looked after well and had a fantastic anaesthetist who explained everything to me. All staff were excellent. I was treated with respect and staff were discreet when taking the catheter out.

Staff were up-to-date with their training in: • Safeguarding training for children and young people and adults. • Mental Capacity Act (MCA). • Deprivation of Liberty Safeguards (DoLS). • Consent. Staff received training in MCA and DoLS, which was held via teams and had over 25 staff members in attendance. Staff had further opportunities to review the training video and PowerPoint slides at a later date. We reviewed the safeguarding training which included the escalation protocol. The named safeguarding leads were identified via their names and photographic identification. The safeguarding training was detailed and referred to the policies: Safeguarding Children and Safeguarding Adults at Risk. The director of quality confirmed that all staff were trained at level one and level two safeguarding for children and adults. Staff had training on how to recognise and report abuse and they knew how to apply it. We saw evidence that safeguarding training was: • 100% compliant for ward staff for both adult and children and young people. • 100% compliant for bank ward staff for safeguarding adults and 98% compliant for children and young people. • 95% compliant for theatre staff for both adult and children and young people. We spoke with the director of quality who had a clear understanding on the types of abuse including female genital mutilation. The Director of Quality was trained at level four in safeguarding and was in the process of being trained at level 5 safeguarding. On competition in June 2024, the director of quality will become level 5 safeguarding lead for the hospital. Nursing staff we spoke to were aware of the hospital’s safeguarding policy and who to contact regarding the escalation of concerns relating to safeguarding. There was a dedicated safeguarding team, which consisted of a safeguarding lead supported by two senior nurses. We reviewed the MCA policy and (DoLS) policy which was in date and next due for review in June 2024.

No safeguarding incidents occurred at the Weymouth Street Hospital over the last 12 months. However, we saw evidence of shared learning from a safeguarding incident that occurred at another hospital within Phoenix Hospital Group in February 2024. A poster had been created by the provider which contained details of the safeguarding escalation and outcome. We also saw evidence of shared learning from other providers where a safeguarding referral had been made. This learning was shared at staff huddle meetings and via email. We looked at the annual safeguarding audit which was traffic light rated; red, amber and green and showed 97% compliance. There was an action plan in place to achieve 100% compliance with a suitable timescale to achieve this. The provider used a checklist for vetting new staff which included checks for the right to work in the UK, Disclosure and Barring Service (DBS), and references. All members of staff employed by the Phoenix Hospital Group had DBS checks carried out. All clinical staff had enhanced DBS checks. We saw evidence that the hospital had checked DBS status for 100% of staff. This included booking coordinators, porters, guest supports, as well as all medical staff. The director of quality informed us that no disciplinary action that had taken place in the last 12 months. But they told us that staff reporting culture had improved over the last couple of years. The provider used hospital passports for patients living with Autism. The form was detailed and included details of the nearest NHS facility that could be contacted for advice. There was also a contact number for the local community learning disability team.

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.

Patients described their care as safe and comfortable. A patient we spoke with said ‘’the room is comfortable and the facilities are good”.

Personal Protective Equipment (PPE), including scrubs, clogs, hats, gloves and eye shields were readily available for staff and we observed staff wearing PPE where appropriate. People were cared for in safe environments that are designed to meet their needs. We looked at audits for decontamination of medical devices and equipment, which all showed 100% compliance of the 14 standards measured. The audit demonstrated that appropriate PPE was worn during decontamination processes and cleaning schedules were in place for all medical devices and other patient related equipment. Patients’ bedrooms were clean and many bedrooms had an ensuite to enable privacy and dignity. Daily room checks ensured that appropriate medical equipment was available and equipment was kept in secure cupboards, such as incontinence pads. The hospital took measures to protect people, service users and the building from fire and obtained a fire alarm test certificate in November 2023. Health and safety procedures including fire alarm procedures were on display and included names of 9 staff who were fire marshals. Call points, smoke detectors, heat detectors and sounders were tested and approved by an engineer. Evidence that showed staff tested fire alarms weekly.

The hospital outsourced sterilisation of surgical instruments. We saw evidence of a rolling contract variation for the supply of sterile services for The Weymouth Clinic Limited last signed by the CEO in January 2024. Equipment used to deliver care and treatment was suitable for the intended purpose, stored securely and used properly. There were effective arrangements to monitor the safety and upkeep of the premises. Staff were trained to use equipment. The service had enough suitable equipment to help them to safely care for patients. The medical equipment log and schedule showed that all equipment was up-to-date with their maintenance. Facilities, equipment and technology were well-maintained and consistently support staff to deliver safe and effective care. Staff carried out daily safety checks of specialist equipment. We received evidence of certified training for 8 nurses for the use of medical equipment. This included the fluid management system, and the hysteroscopic tissued removal system. Staff carried out daily checks for room temperature, call bells, glucometers, resuscitation trolleys, defibrillators and capnographs. Staff signed and dated all documents to confirm that daily checks were carried out. Wards were visibly clean and spacious. Equipment was accessible for resuscitation, oxygen and suction. Clinical rooms had the necessary medical equipment and medicines. Patient beds were fitted with a sticker stating the maximum weight load it could bare. The utility rooms were clean and shelves were clearly labelled, soap and alcohol gel were available by the wash basin and hand hygiene posters were on display. Sharps boxes were closed, signed and dated and the medicines cupboards were locked and stored securely. All electrical items had passed the portable electrical safety test and was next due for testing in March 2024.

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.