University Hospital

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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

We rated effective as good. We assessed 6 quality statements. Staff monitored the effectiveness of care and treatment, completed risk assessments for each patient on admission and reviewed them regularly. Assessments were up-to-date and staff understood people's current needs. Staff supported patients to make informed decisions about their care and treatment. Managers used information from the audits to improve care and treatment and made sure staff understood information from the audits.

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.

We did not look at Assessing needs during this assessment. The score for this quality statement is based on the previous rating for Effective.

People’s experience

Patients reported receiving information and advice about their health, care, and support to help them achieve the best possible physical, mental, and emotional well-being. Each patient had their individual risks assessed in line with national guidance and best practice guidelines.

Patients who underwent spinal surgery were prescribed patient-controlled analgesia and received 2-hourly observations for the first 24 hours. Staff assessed patients’ nutrition and hydration needs daily and took appropriate action based on their findings.

Feedback from staff and leaders

Staff followed up-to-date policies to plan and deliver high quality care according to best practice and national guidance.

The service promoted the use of subject leads, these included but were not restricted to diabetes, sepsis, mental health, learning disabilities, falls, tissue viability and autism. Staff with this specialist knowledge could offer additional up to date advice or support to other staff working with a patient with additional or complex needs.

Processes

Care was provided in line with national clinical guidelines and quality standards set by Royal Colleges and the National Institute for Health and Care Excellence.

Patients had their individual health risks assessed. The introduction of the electronic patient records system meant staff were prompted to complete all the relevant risk assessment for each patient and would not permit the staff to move forward on the system until all the assessments had been completed.

The service used clinical tools tailored to patients' needs, such as WHO checklists, mobility assessments, and falls risk assessments. Records were kept up to date and reflected comprehensive assessments, ensuring effective ongoing care.

Additionally, the acute team recently developed post-operative pain guidance, which was approved by the Royal College of Physicians.

Clinical outcomes and complication rates were audited. The surgical division made regular data submissions to national audit programmes.

Patients’ needs were assessed to ensure care and treatment was appropriate and based on individual needs. Assessments considered the person’s health, care, wellbeing and communication, cultural and religious needs to ensure outcomes were as good as possible. Assessments were completed to enable the treatment for the patient to be tailored to meet individual need and deliver the best outcome.

People’s experience

Patients told us they received care from multidisciplinary teams. For example, speech and language therapists, physiotherapists, occupational therapists, pharmacists and mental health teams.

Feedback from staff and leaders

All staff told us they were well supported and were proud of their ability to deliver multidisciplinary care. They were happy in their role and felt all members of the wider team functioned well and team communication was good.

Staff ensured they followed guidance and maintained good record keeping of the multidisciplinary care provided.

Feedback from partners

External care providers, such as social workers and community occupational therapists, could access patient notes as required.

Observation

In the trauma theatre, we observed the team working effectively together, with clear direction from the operating surgeon and scrub nurse. The safety checklist was completed, and the process appeared well established. Staff were aware of a student present in the theatre, ensuring they followed sterile procedures while also considering their welfare.

We observed a theatre huddle led by the theatre manager. All team leaders attended, and feedback was provided on late starts. Discussions included which patients had been called for and any equipment issues. Updates on the current status of theatres and any escalations were reported to the site meeting.

We also attended a morning theatre team brief, where cases were reviewed, and leaders checked in with staff to identify any concerns before the main theatre briefing.

Additionally, we saw that the trust supported staff development by introducing and increasing the number of new roles, such as advanced clinical practitioners in clinical areas.

The medical records we viewed indicated a multidisciplinary approach to care delivery.

Processes

Discharge planning began as early as possible. Staff followed clear pathways to ensure patients received the necessary care. Some pathways involved transitioning between services, such as when a patient needed to be transferred elsewhere. Staff understood how to properly hand over patients and refer them to the appropriate services when needed.

We did not look at Supporting people to live healthier lives during this assessment. The score for this quality statement is based on the previous rating for Effective.

People’s experience

Patients told us they had a range of risk assessments undertaken to ensure their care followed national guidance.

Feedback from staff and leaders

Staff were aware of the audit activity in their clinical areas and knew what the audit outcomes were. This information was shared with them on their communication boards, in emails, at staff meetings and safety huddles and at governance meetings.

Processes

A total of 20 specialty-level clinical audits had been completed. These included 6 in trauma and orthopaedics, 4 in cardiothoracic surgery, 3 in upper gastrointestinal surgery, and 2 in vascular surgery. Neurosurgery, anaesthetics, ear, nose and throat and urology had each completed 1 audit. We reviewed a brief summary of the outcomes and any actions taken where applicable.

The audit forward programme for April 2024 to March 2025, outlined the national mandatory clinical audits and service-priority audits for surgery, trauma and orthopaedic, neurosurgery, cardiothoracic surgery, theatres, and anaesthetics. A total of 27 audits were planned, with most already in progress. The majority were on track according to the risk rating system. Two audits were rated amber, indicating delays with actions established to recover progress, while another 2 had yet to begin, as they were scheduled for January to March 2025.

Sepsis audits showed compliance rates of 80% in June 2024, 46% in July 2024, and 100% in August 2024. The action plan, dated September 2024, identified 1 key area for improvement - the 1-hour treatment target. National Early Warning Score fluid balance audits from March to June 2024 showed an average compliance of 74%. Monthly compliance for weight recording ranged from 77% to 91%, while compliance with Malnutrition Universal Screening Tool (MUST) completion ranged from 86% to 100%. Venous thromboembolism (VTE) risk assessment from January to June 2024 showed a compliance of between 64% to 94%. Theatre teams brief and pre-operative checklists included a prompt to consider VTE advanced preventative prescribing (prophylaxis).

We were aware of the challenges related to the electronic patient record roll out and the impact on the audit results during this period. Audit compliance rates in all areas had improved at our March 2025 inspection. Particular improvement was noted on ward 22 where audit compliance had significantly improved in all areas. We also noted improvement in patient satisfaction on this ward.

These audits formed part of the matrons' assurance checklist and audits were undertaken daily, weekly and monthly. Staff received immediate feedback, and key themes and issues were discussed at safety huddles and ward meetings.

A theatre pressure ulcer report from April to September 2024 showed there were 4 category 2 pressure ulcers in April and 1 in September 2024. In response to this the trust had rolled out a 4-hourly stop and check process for long theatre cases. The department were also trialling a new product to reduce airway tapes and ties which had caused irritation in some cases.

The department carried out regular pain audits. The most recent fractured neck of femur results saw a decrease in analgesia prescribing to 61% after admission. However, there was an action plan to address this, and re-audit of compliance arranged. Audit findings were shared routinely with staff at governance meetings.

Outcomes

The department participated in national audits for the period 2023 to 2024. We saw summaries of how findings had been appropriately responded to. Audit outcomes and associated learning was shared from this through the mortality and morbidity (MM) meetings and governance meetings. We reviewed a sample of MM meetings minutes from 3 specialities and found they were used to identify learning and improve practice. They contained evidence of a proactive audit culture in the department that focused on clinical safety and improved outcomes for patients.

People’s experience

Patients we talked with told us they were given sufficient information to be able to make informed choices about their care and treatment. This included information about the risks associated with surgery and having a general anaesthetic.

Feedback from staff and leaders

Staff told us they provided patients with relevant condition-specific information. This was provided in verbal and written format and sometimes in specific languages.

Staff knew how and when to assess a patient’s mental capacity to make decisions about their care. They received regular training on the Mental Capacity Act to stay up to date and ensure they understood patients' rights and the legal requirements for consent.

All 3 consent forms we reviewed on the day care unit, were accurate and reflected possible complications. We also looked at 5 in the ward areas and found them to be fully completed.

Processes

The consent process followed legal and ethical guidelines to ensure patients made informed decisions about their care and treatment. Staff obtained consent after providing patients with all relevant information. Records we viewed showed consent forms were fully competed.

Patient records showed that capacity and psychological well-being were assessed on admission. Where necessary, staff completed mental capacity assessments in line with the Mental Capacity Act. Staff understood how to support patients who lacked capacity or were experiencing mental ill health, ensuring decisions were made in their best interests.