Victoria Infirmary

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

This means we looked for evidence that the service met people’s needs.

We last inspected the service, in 2014 in combination with diagnostics and with the other location. At our last assessment we rated this key question requires improvement. At this assessment, the rating has improved to good.

This meant people’s needs were met through good organisation and delivery.

We have not awarded this service a score for Responsive.

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

The evidence showed a good standard. The service made sure people were at the centre of their care and treatment choices and they decided, in partnership with people, how to respond to any relevant changes in people’s needs.

Staff made reasonable adjustments for patients.

A stretcher SOP had been introduced to support patients arriving by ambulance. This included liaison between the NHS ambulance service and the outpatient’s department. The service was aware of when patients were expected to arrive by ambulance and they were assigned to a consulting room that could accommodate a stretcher, including bariatric patients. This meant there was a private area where these patients could wait. Department stretchers were required to have bed rails for safety of patients.

The service received notifications three times a week regarding expected stretchers and patients in wheelchairs.

Patients were given a ‘pink’ card on arrival to alert staff of ambulance transportation. These were useful if patients attended different locations in the department such as ophthalmology.

Toilets for disabled people were accessible. There was a hearing loop for those with a hearing impairment.

Care rounds had been introduced in case of delays and pressure relieving cushions and mattresses toppers were available if needed.

In November 2025, a PLACE inspection of the location scored 94% for dementia friendly and 93% for disability friendly.

Blindness awareness training had been delivered to improve staff understanding of visual impairment and to support patients attending the service for ophthalmic appointments. The training provided practical solutions to support patients respectfully in the department.

The evidence showed a good standard. The service understood the diverse health and care needs of people and their local communities, so care was joined-up, flexible and supported choice and continuity.

There was a trust wide patient access policy and a SOP for the records system in the department. Patients could book appointments on the trust electronic system. Patients we spoke with told us it was straightforward and they had the option to book at this or another location. Appointments were described as timely, with no difficulties reported in rescheduling appointments when required. Communication was hailed as a strength of the service by patients. Staff kept patients informed when in the department, including updates regarding any delays which had a positive impact on making the patient feel valued and considered. Posters displayed in reception encouraged patients to speak up if they had waited longer than 30 minutes for their appointment. Patients we spoke with told us they didn’t wait long to be seen in the department.

In the main reception there were vending machines with snacks, a hot drinks machine and a water fountain. There were no eating areas in the hospital. A mobile food truck from an external company visited at lunchtimes for staff. There were plans to reintroduce an internal service where people could purchase food and drinks in the future.

Car parking at the hospital was limited and patients expressed concerns about difficulties. However, the trust were aware of these concerns and informed us about plans to expand the car park in the future.

The evidence showed a good standard. The service supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

Information governance systems supported the secure handling of information and maintenance of confidentiality. Patient records were stored securely in a locked room or in locked notes trolleys when not in use by the clinical staff.

The service complied with the Accessible Information Standard.

There was a trust wide interpreter and translation service for patients whose first language was not English. British sigh language interpreters were available for patients with a hearing disability. There was a trust wide policy as well as an interpreting and translation staff guide. There was a SOP for the accessible information standard. Interpreters could be pre-booked to support patients whose first language was not English. A hearing loop was available and leaflets were available in a range of formats.

Staff ensured that patients could obtain information on treatments and local services including how to complain. Information was displayed about how to feedback about the service as well as an interactive display with trust information.

Notice boards displayed information both for staff and patients such as Clare's Law, details about providing feedback to CQC and performance information such as FFT, cleanliness, attendances and DNA’s.

There was an extensive range of patient information leaflets, for a range of specialities, that could be given both on paper and electronically. The service had developed and provided an electronic version where a QR Code was accessed. These were available in multiple languages other than English and other formats such as larger fonts.

The evidence showed a good standard. The service made it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. They involved people in decisions about their care and told them what had changed as a result.

Information about how to contact managers, with any queries, was displayed for patients alongside ‘you said, we did’ actions.

There were boxes in reception where patients could feedback including friends and family and ‘bright ideas.’

There was a trust wide complaints and concerns handling policy. There had been no formal complaints since 2021 and no referrals to the parliamentary and health service ombudsman (PHSO). Between April 2025 to March 2026 there had been 7 concerns raised with the patient advice and liaison service (PALS), 2 of which were related to community services and 3 regarding car parking issues.

The service received 304 compliments. Feedback described staff as "professional", "kind", "courteous", and "extremely caring". Patients also reported being "well looked after", "treated very well", and "put at ease", and commented positively on communication and the overall atmosphere of the service.

The evidence showed some shortfalls. The service did not always make sure that people could access the care, support and treatment they needed when they needed it.

Most outpatient clinics operated Monday to Friday, between April 2025 and March 2026, there was a total of 16264 attendances at the service. The highest attendances were for dermatology with 4257 and ophthalmology at 3894.

The overall clinic utilisation at this hospital was 69% with some lower such as face to face dermatology follow up that was at 30% and orthopaedic follow up was at 29%, whereas new ophthalmology for glaucoma was at 86%.

A utilisation of 69% was equivalent to 1694 appointment slots monthly with only 1173 being used. This utilisation had improved from 65% and the trust was developing a clinic utilisation dashboard with an external organisation. Challenges in improving utilisation had been identified with plans in place to address these.

The responsibility for monitoring clinic utilisation was with individual specialities rather than with the outpatients as it did not set clinic templates or complete appointment bookings. Pre-appointment reminder processes were being reviewed to support short notice cancellations as well as exploring new ways of validating patients who no longer required appointments and self-booking systems.

The information currently available was collected at trust level for each speciality. We were told that each speciality monitored their referral to treatments rather than the outpatient department. Between January 2026 and April 2026, there was an average of 1632 referrals per week, across the trust. Referral to Treatment (RTT) waiting times monitor the amount of time from referral to the start of treatment. The NHS aims for 92% of patient to start treatment within 18 weeks of referral. Data from April 2026 showed that the trust wide performance was 63.7%.

The overall cancellation rate was 23%, with 11% cancelled by the service and 12% patient cancellations. In addition, 53% of appointment cancellations were by patient choice and this was the highest reason for cancellations. There were 30% of appointments that were cancelled clinic sessions by the hospital.

Between April 2025 and March 2026, there was a did not attend (DNA) rate for the hospital of 8% which was higher than the trust DNA rate of 7%.

In April 2026, the trust commenced a pilot of a patient engagement platform to increase the reutilisation of appointments cancelled by patients.

We were told that there could be challenges with doctor availability due to them working at both hospital sites for clinics, ward or on call duties.

The trust was developing a dashboard that would include performance metrics. These could be monitored waiting list sizes and patient waiting times through divisional and trust performance management group meetings.

The evidence showed a good standard. Staff and leaders actively listened to information about people who are most likely to experience inequality in experience or outcomes and tailored their care, support and treatment in response to this.

Staff within the service and the wider organisation promoted a culture in which the people using the service felt empowered to give their views.

The provider had undertaken equality impact assessments of their policies and procedures to ensure they did not place vulnerable people or people with protected characteristics at a disadvantage.

There was a trust wide Equality, Diversity & Human Rights Policy that provided guidance for staff on delivering inclusive care and meeting the needs of people with protected characteristics, including transgender people.

The trust monitored the ethnicity, gender, age and disability status for patients attending the department. Between April 2025 and March 2026, of the total 16264 attendances, the greatest number of patients by age was in the 68 years old to 84 years old category with 5542 attendances. The greatest number of patients by ethnicity were white British with 1389 attendances.

The trust systems did not breakdown information regarding disabilities except for learning disabilities and autism. For the same time period there had been 76 attendances.

Staff completed training in equality, diversity and human rights as part of mandatory requirements. There was a compliance of 100%. However, there were no results for supporting patients with learning disabilities or mental health needs.

The hospital had access to 15 standard wheelchairs and a bariatric wheelchair. We saw that wheelchairs were readily available in the reception area. Chairs in the outpatients waiting area were a variety of styles and sizes suitable for people who may have reduced mobility or bariatric needs. The main hospital reception had standard chairs.

For patients who preferred a quiet waiting room, such as those with a sensory need, an area had been designated to support these patients away from main reception.

The evidence showed a good standard. People were supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.

We observed that consultations included discussions with patients and those close to them about ongoing care and treatment.

Patients we spoke with told us that staff communication was excellent and they felt informed.

Staff demonstrated an understanding of DNACPR (Do Not Attempt Cardiopulmonary Resuscitation) forms. However, due to the new electronic patient record system staff could not always tell us where resuscitation decisions would be recorded. We raised this at the time of inspection with leaders who took immediate action to reduce this risk.