Goole & District 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

We assessed 8 quality statements for this key question. We looked for evidence that safety was a priority for everyone, and leaders embedded a culture of openness and collaboration. We checked to see if people were safe and protected from bullying, harassment, avoidable harm, neglect, abuse and discrimination.

At our last assessment we rated this key question good. At this assessment the rating has remained good. This meant people were safe and protected from avoidable harm.

At this assessment we identified a breach of regulation in relation to Safe care and treatment.

We have not awarded this service a score for Safe.

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

We scored the service as 2. The evidence showed some shortfalls. The service did not always have a proactive and positive culture of safety based on openness and honesty. Leaders did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

Patients we spoke to told us they felt safe whilst in the department.

We saw patients report problems to the administration staff. These staff treated patients with compassion and understanding while they helped fix any issues.

Leaders told us they held daily and monthly meetings to discuss safety events and risks. They explained how they shared this information with the team. Leads described how they managed complaints and shared the common themes.

At departmental daily safety meetings leaders discussed staff allocation, service planning, infection control issues, safeguarding and any other safety issues which could affect the service.

Some staff told us they knew which incidents to report and how to report them. Others were less sure about the process, but all said they would tell their managers. Staff told us they felt safe to raise concerns with their managers.

Staff described how they received feedback from investigations of incidents. This occurred both within the service and from other sites, through the morning safety meeting. We saw learning shared from serious patient safety events (PSEs) at other trust sites. For example, leaders shared immediate learning from a serious PSE at another site the day before.

We saw a poster about a serious incident involving a patient allergy, available for staff to read. We also saw posters telling patients how to raise concerns with the Patient Liaison Service or how to make a formal complaint.

However, staff had reported only one safety event in the 12 months before our assessment. This number was much lower than other outpatient departments in the same trust. We saw two safety incidents during our visit which should have been reported but were not. This meant we were not assured staff understood which patient safety events needed reporting to support learning across the service and the hospital.

Staff showed us the “Quality Times” which shared innovation and learning from across the hospital sites.

All the staff we spoke to explained what duty of candour meant. They described the importance of being open and honest, and pointed out posters on the department walls for patient information.

We saw confidential locked boxes in the department where staff could raise issues anonymously, Friends and Family boxes and posters allowed patients to give feedback on the service. The Trust had not undertaken a patient experience survey in outpatients within the past 12 months.

Staff received updates on Integrated Operational Pressures Escalation Levels (OPEL) in line with NHS England’s framework. These updates helped them communicate how they managed operational pressures and shared safety alerts from other trust and Humber Partnership sites.

We scored the service as 2. The evidence showed some shortfalls. The service did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

Patients told us the service supported them at first appointment and follow up. They said they had received both verbal and written explanations of treatment options.

The service accepted patients based on clinical appropriateness. Appointment criteria had recently been updated following consultation with NHS Humber and North Yorkshire Integrated Care Board (ICB), who plan and pay for the service.

Leaders we spoke with explained how they managed the waiting lists. They held weekly meetings to support the management of clinic capacity. Policies were in place to support this.

Paper medical records were available for the clinics. They were all stored securely. Visible posters reminded staff to ensure medical records were face down, safe and secure.

We found staff completed no documentation relating to outpatient visits in the paper copies of patients medical records we reviewed. Staff had no designated place to record observations or the results of tests they undertook in the main record. The trust was in the process of moving to an electronic patient record (EPR), the Outpatients department had not moved over to this yet. This meant we were not assured that care delivered and clinical observations recorded during outpatient appointment were consistently captured in a single, accessible record for continuity and oversight. It had not been reported as a safety event and did not appear in minutes of monthly matron’s meetings. This is a breach of regulation (Regulation 12).

A standard operating procedure (SOP) was in place to support the management of patients who had deteriorated. However, this SOP was five years overdue for review. This meant we could not ensure it reflected current legislation or operational practice.

Despite this, all staff could explain the process they followed and actions they would take if a patient became unwell in the department. They provided examples of when this had occurred. Posters in each clinical room clearly set out these actions and the appropriate contacts in the event a patient became unwell.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Staff and leaders received role‑specific training on recognising and reporting abuse. Compliance with both adult and children’s safeguarding was above the trust’s target of 85%. Staff had received the appropriate safeguarding training in line with the intercollegiate requirements.

Staff and leaders told us they knew how to identify adults and children at risk of, or experiencing, significant harm. They knew how to make a safeguarding referral and who to inform if they had concerns. Staff had access to the safeguarding reporting system and a safeguarding file in the ward manager’s office.

Clinical rooms displayed telephone numbers for safeguarding support.

Leaders gave examples of safeguarding referrals they had made in the past. They explained how they worked with external partners to support patients.

However, a review of the last three months Patient Services Care Group Outpatient Nursing Quality Governance meeting minutes, which the manager attended, showed no discussion or standing agenda item on safeguarding.

Although staff understood the safeguarding process, they told us they had not submitted any safeguarding referrals in the 12 months before the assessment.

We scored the service as 3. The evidence showed a good standard. The service worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Patients we spoke with said staff gave them a full explanation of their treatment, including the risks. They provided written information to take home. Patients said staff explained this in a way they could understand.

Staff told us how they communicated with patients who had communication difficulties. We saw staff speaking with patients in ways which helped them understand their care and treatment.

The service collected monthly friends and family feedback and shared the results with staff at the morning huddle. We reviewed 13 months of data, which showed mostly positive feedback. We saw posters asking patients for feedback and posters displaying patient feedback. Patient feedback was displayed on the wall in the department.

Leaders told us they shared risks to service delivery during morning huddle meetings. We observed this on site. At these meetings, leaders discussed drug alerts, incidents and patients who needed additional assistance.

Leaders told us about the monthly governance meetings where learning, risks and policies were reviewed. We reviewed the meeting minutes and saw departmental managers attended.

Staff told us risk assessments for patients were completed in other areas of the service rather than in the outpatient department. However, they could describe how they would support a patient who became unwell while attending outpatients, and they shared examples of when this had happened.

We scored the service as 3. The evidence showed a good standard. The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

People told us the area was clean and tidy. They felt safe to raise concerns about the environment with the service.

Staff used a daily ‘safe to care’ checklist, covering the environment. This included fire exits, fridge temperature checks, oxygen and medication and resuscitation trolley.

However, clinics did not have bariatric equipment for assessment or consultation, such as wider benches.

Leaders told us the new digital audit software gave staff and managers assurance about hand hygiene, infection control, estates and facilities, and the environment. Leaders were able to describe the process for reporting environmental issues to facilities for repair or replacement and showed us the recording of these requests. They advised facilities were prompt at attending.

Staff told us there had been no fire drills. The Fire Safety Team planned a tabletop fire drill, to take place by the end of March 2026. The service’s fire warden was one of the managers. A completed questionnaire was forwarded to the fire office monthly.

They told us fire alarms were checked weekly. Staff were aware of the emergency exits and fire extinguishers. All fire extinguishers had labels identifying when they were last tested.

Leaders told us the department were required to flush water outlets randomly 5 times a fortnight to prevent Legionella. Staff told us they undertook this daily.

Leaders told us matrons undertook a monthly environmental audit. The Patient Environment Action Team (PEAT) visited the ward to review the environment.

Certificates in the waiting area demonstrated compliance with the 15 step challenge (a toolkit to help see the service through the eyes of the patient).

We observed areas were clean and well maintained with no clutter in the corridors. Equipment was in good working order. An in-date cleanliness rating and summary were visible on the wall in the waiting area. However, some ceiling panels areas were damp following recent rain. Staff told us these had been reported.

The department was clearly signposted. The entrance was not locked, owing to it being an outpatient’s department. We observed appropriately locked and swipe access doors in all secure areas. CCTV cameras were visible monitoring the entrance. All fire exits were clear of obstructions.

Electric equipment had all been portable appliance tested. Consumables were in date. All fluids hazardous to health (Control of Substances Hazardous to Health, COSHH) were locked away.

There was enough storage space available. The store cupboard containing consumables was free from clutter with nothing stored on the ground.

The medication room was locked and the room temperature checked daily. If the temperature rose outside normal range, staff used an electric fan and opened the door if no patients were attending for appointments. However, there was nowhere for staff to record checks to provide assurance the temperature had come back within suitable range. We raised this on site with the ward manager who told us they would amend the record sheet.

We found one oxygen cylinder not secured to wall. However, this had been logged the week before our visit for rectification.

We scored the service as 3. The evidence showed a good standard. The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Patients told us there was enough staff on the department. They added staff had the right skills and training to support their needs. Staff had introduced themselves and were all friendly.

Eleven staff worked in the service, covering weekday clinics morning and afternoon, with one weekly evening clinic. Leaders told us staffing was stable with minimal turnover. The department had no staff on long term sickness and no vacancies. The service did not use agency staff.

We saw a staffing dashboard which recorded planned versus actual staffing numbers for all shifts. Actual numbers met those planned. We observed posters reminding staff what to do if staffing was below planned levels.

Staff told us there had been enough staff on shift to run clinics safely, and breaks were all taken promptly.

Leaders told us they met regularly with the Matron and Human Resources to review staffing issues. The service used E-rostering software to calculate staff rotas to ensure consistency and safety. Leaders shared with CQC monthly governance minutes and reports. These included patients’ safety, patient and carer experience audit, patient stories, compliance and medication issues.

Leaders gave an example of a recent increase in staffing levels to support two healthcare staff. During our assessment they were undertaking their nurse apprenticeship programme, sponsored by the Trust.

The matron undertook annual business planning to ensure correct staffing levels. They did this by reviewing if the departmental services met the local population’s needs.

All staff told us they were up to date with mandatory training and appraisal.

However, appraisal compliance was below the Trust target at 63.7% in February 2026.

Departmental mandatory training overall as of 11 March 2026 was 86% (13 modules). This met the trust’s 85% target. Staff achieved 80% in 2 modules: infection prevention and control Level 2, information governance and data security (2 of the 10 staff had not undergone the training). However, moving and handling module F compliance was only 30% (7 of the 10 staff had not undergone the training). This was significantly below trust target. An alert was sent to the manager when staff’s training compliance was not adhered to.

Role specific training and training in using specialist equipment was complete. For example, the staff nurses in clinic had completed their manual handling for use of the hoist and PAT slide to transport patients.

We spoke with two staff seconded to undertake their nursing apprenticeship. They were both complimentary about the development opportunities available.

Leaders said they were offered development opportunities.

Staff were able to receive clinical supervision led by the ward manager. Posters in the department advertised clinical supervision.

We scored the service as 3. The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Patients told us they had no concerns about cleanliness. Friends and Family Test responses confirmed the department was clean and tidy. Feedback from CQC ‘Have Your Say’ forms reported the environment was clean.

We observed the area was clean, tidy and free from clutter. The required furniture was in place and well maintained. All equipment was visibly clean and carried in‑date ‘I am clean’ stickers.

Staff described the daily cleaning processes and checks. We reviewed the ‘Safe to Care’ daily checklist. This included equipment and alcohol gel checks. Staff explained the ‘five moments’ for cleaning, including cleaning beds and equipment, handwashing and storing equipment correctly.

Leaders described the ward assurance tool and ‘five moments’ audit process. Audit results were recorded on the Audit Management and Tracking (AMaT) system, and reports were available to leaders. The service had a link IPC nurse, and the infection prevention and control specialist carried out monthly audits.

Staff told us about a recently introduced cleaning solution and clearly described how they used and stored it. We saw posters demonstrating its safe use.

Monthly hand hygiene audits were submitted. January 2026 compliance was 100%. A housekeeper/cleaner worked on duty each evening. In‑date hand sanitiser was available at the department entrance.

We observed staff either washing their hands or using hand sanitiser appropriately. All staff were bare below the elbows during patient contact, and all were uniform compliant. Clinic rooms had sinks with elbow‑operated taps to reduce contamination risk.

Toilets and hygiene areas displayed posters reminding staff of hand hygiene procedures and the five principles of cleaning.

We saw IPC displays in the department; however, they did not include recent audit data. The department had side rooms for patients with infections or awaiting screening results.

A colour‑coding poster for cleaning materials was clearly displayed. We observed a sepsis display in the patient area. This explained the signs of sepsis and how to reduce the risk.

We scored the service as 3. The evidence showed a good standard. The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happen.

We spoke with patients as part of the on-site visit, reviewed friends and family responses and CQC have you say responses for 2025. Patients had not expressed any concerns relating to medicines management.

Medicines were ordered from a local external pharmacy department. Staff said there had been no issues with supplies. No controlled drugs were kept on site.

Medicines for routine clinical use were stored securely in a utility room requiring electronic access, in a locked medicines cabinet which was securely attached to the wall.

We observed and reviewed medicines management arrangement including storage and security checks for medicines and prescription administration. Staff described how they followed relevant trust processes for ordering, storage, administration and disposal.

The service kept emergency medicines and portable oxygen cylinders stored on a tag-sealed resuscitation trolley. This was appropriately stocked and checked routinely. All medication was sealed correctly and in date. All electrical equipment was in date.

Prescription pads were kept in a locked office during non-working hours. During working hours, they were locked in a cupboard. Prescription numbers were recorded every time one was taken for use.