Victoria Infirmary

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• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

This means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

We last inspected the service, in 2014 in combination with diagnostics and with the other location. At our last assessment we did not rate this key question. At this assessment, we rated this key question as good.

This meant people’s outcomes were consistently good, and people’s feedback confirmed this.

We have not awarded this service a score for Effective.

Find out about when we will not publish a key question score and what we look at when we assess Effective.

The evidence showed a good standard. The service made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

Staff used a range of tools to assess and review people’s health needs. The tools were standardised, so staff understood how to use them. The type of tools used to record and monitor people’s health depended on the clinic being held, and the individual needs of the patient. For example, blood glucose monitoring for patients with diabetes, and venous thromboembolism assessment for patients who were being considered for surgery.

The evidence showed a good standard. The service planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation and current evidence-based good practice and standards.

The service participated in internal audits, including monthly data quality audits that had been adapted for outpatient areas. Results were displayed at the service and visible to staff, patients and visitors.

Staff followed policies that were generally up to date to plan and deliver high quality care according to best practice and national guidance. There were systems to communicate changes in guidance through meetings and management newsletters. We saw notice boards displaying up to date guidance for staff to follow.

Monthly outpatient audits were completed. Staff generally scored highly (mainly 100%) with a strong focus on effective communication between staff and patients, such as patients being given enough information about their care and treatment or staff awareness about accessing alternative communication aids including interpreters or patients who required reasonable adjustments.

The evidence showed a good standard. The service worked well across teams and services to support people. They made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services.

The teams had effective working relationships with other relevant teams within the organisation. Administrative staff supported referrals and booking of further appointments or investigations.

There were multiple specialities that utilised the outpatient department. We saw that staff worked well together.

Staff shared information about clinic lists in daily huddles at the start of the shift. We observed a huddle and noted it included details about clinics for that day as well as cancelled clinics. Staff that were present were allocated and areas requiring cover discussed. Information was shared both internally and from across the trust. We requested details of any team meetings held, however did not receive any.

Senior staff held regular and effective multidisciplinary meetings.

The evidence showed a good standard. The service supported people to manage their health and wellbeing to maximise their independence, choice and control. The service supported people to live healthier lives and where possible, reduced their future needs for care and support.

Staff supported patients to live healthier lives. We were told that the trust had embedded their commitment to health self-management and wellbeing support into care for patients and staff. There were condition specific leaflets available as well as electronic versions accessed by QR codes.

There was an individual placement support (IPS) service available that could provide individualised support to people using the service about accessing employment.

The evidence showed a good standard. The service routinely monitored people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves.

We requested details of clinical audits that outpatients participated in, however we only received data relating to internal monthly audits regarding the environment, communication and nursing care.

We were told that responsibility for the ongoing management of clinical care, treatment pathways and patient outcomes sits with the relevant clinical specialty rather than the outpatient location itself. Trust governance processes included clinical audit programmes, which included review and improvement of clinical care and patient outcomes.

We observed that many of the patients were frequent attenders to the service, such as ophthalmology patients who required regular treatments. Patients were monitored at each appointment with outcomes recorded by clinicians in patient records. These were individualised to patient need.

The service had been involved in research studies for a range of specialities that could support improvements in patient outcomes.

We scored the service as 3. The evidence showed a good standard. The service told people about their rights around consent and respected these when delivering person-centred care and treatment.

There was a trust wide policy for adult consent to examination, treatment or postmortem and consent to examination and treatment for children and young people policy. In addition, there was a trust wide mental capacity assessment process and deprivation of liberty safeguards (DoLS) policy.

The consent process began at initial consultation and was confirmed at various points in the patient pathway. We observed staff gaining verbal consent when supporting patients. When patients were unable to provide informed consent, staff worked with carers and relevant others to support decision-making and, where necessary, undertook best interest decision-making in line with the Mental Capacity Act 2005.

A consent audit took place in August 2025 at the hospital, however, the service was not included. There was a plan to be included in the audit scheduled for July 2026.