University 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

Patients were confident they could raise concerns and felt staff would respond appropriately. Patients and their relatives were involved in investigations and received reports, learning outcomes, and details of any associated service improvements.

While patients had to wait in clinical order to be seen on the surgical assessment unit, the recent review of patient pathways and staff deployment had improved efficiency and made a difference to the patients' overall experience.

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.

People's experience

Patients were confident they could raise concerns and felt staff would respond appropriately. Patients and their relatives were involved in investigations and received reports, learning outcomes, and details of any associated service improvements.

While patients had to wait in clinical order to be seen on the surgical assessment unit, the recent review of patient pathways and staff deployment had improved efficiency and made a difference to the patients' overall experience.

Feedback from staff and leaders

Incidents were reported using the electronic reporting system and escalated to the appropriate manager. Incidents were discussed with staff. They were formally investigated, and the associated learning was shared at an individual as well as departmental level. Trend and themes from incidents were reviewed by the Quality Improvement and Patient Safety Group.

Staff were generally aware of the processes for learning from incidents and felt well-supported, with effective learning provided when incidents occurred. Most staff were able to give examples of a recent incident, never event or complaint. Learning from incidents was included in the staff monthly newsletter, safety huddles and emailed to all staff.

The practice educators for the surgical services group reviewed safety incidents and provided additional training and support to staff when needed.

There were monthly governance meetings for all specialities to review their audit outcomes. Theatre workshops were also provided to new staff to ensure they had access to additional learning and support in their new role.

There were electronic processes to ensure good oversight of mandatory training compliance. Managers were informed when mandatory training was due and could book staff onto training.

Staff received sepsis training and there was a renewed trust wide focus during September. `Sepsis September' saw over 150 staff receive training on using the sepsis elements of the new electronic patient record.

Processes

There were processes for staff to follow when reporting incidents. Staff were aware of the incident reporting process. Incidents were an agenda item on each specialities governance meeting. We saw a copy of the staff newsletter on the staff board in theatre, which included a summary of incidents trends and themes and associated learning.

Between September 2023 and 2024, a total of 4,610 incidents were reported within the surgical service at this location. The majority of these were recorded as no harm incidents and low harm incidents. Leaders were confident there was a healthy safety culture in the service which meant staff actively ensured safety incidents were reported.

In September 2024 we noted a high number of incidents about staffing levels on Surgical Assessment Unit (SAU). Themes included long delays for surgical doctor reviews and delays in transfers for those patients who required medical rather than surgical care and long delays for patients waiting to be assessed. Our March 2025 inspection showed improvements in many areas on this unit. For example, the staffing templates and the way staff were deployed was reviewed. The patient pathways were also reviewed and had been changed to ensure a more effective and responsive service for patients.

The trust held SWARM huddles, which identify learning from patient safety incidents, immediately after an incident. A SWARM can be defined as a structured response to an incident or near-miss, designed to support learning and improvement. It involves gathering a multidisciplinary team immediately after an event to discuss what happened, identify contributing factors, and consider actions to prevent recurrence, which leaders described as a no-blame approach designed to support staff and families. Lessons learned from incidents were shared across teams and discussed at the group board.

Staff that had completed mandatory training and were able to describe how this had increased their knowledge and benefited their work. Data received in September 2024 showed the overall compliance with mandatory training for staff working in all surgical services was 93%. Resuscitation training was 85% and advanced life support was 81%. Adult and paediatric immediate life support were at 74% and 81% respectively. Compliance with learning disability and autism training was 89%. Compliance had improved at our March 2025 inspection.

People’s experience

Patients we spoke with told us they felt safe in the service. They knew how to raise concerns and felt confident the service would take their views and opinions would be taken seriously. Those we spoke to felt they had received sufficient information to make informed choices about their care and treatment.

Some patients told us they experienced long waits for surgery, but they were very pleased with the service they received once they were admitted.

Feedback from staff and leaders

Staff from different specialties worked together and with other agencies when they needed to care for patients. During our assessment, we saw physiotherapists, occupational therapists, and speech and language therapists working closely with ward and theatre staff to give holistic care and treatment. Staff held meetings to discuss feedback and find ways to improve patient care. Leaders then shared updates on these improvements during safety huddles.

In September 2024, staff told us the transition to the new electronic patient record system had been challenging. Staff told us they found the system confusing; documents were not always easy to find; and they were spending longer on completing and updating records. We were also made aware the new electronic patient record had caused delays in booking patients for theatre.

During the March 2025 site visit most staff we talked with told us they had a growing assurance in the electronic patient record system and felt more confident to use it. To support staff with the transition the trust gave matrons dedicated time to provide one to one staff training to support staff development needs. This had a positive impact on staff and improved their competence and confidence in using the new system. Continuous training resources and dedicated support remained in place for all staff. However, we spoke to a small number of staff who told us they were still struggling. Continuous training resources and dedicated support was available for all staff.

Our March assessment audit data showed significant improvement in all areas on this ward. The trust had supported the matrons to focus on supporting staff and monitoring clinical care through audits and clinical observation of the care delivered.

We saw documented evidence that NEWSs were recorded and acted upon when the clinical signs of deterioration were identified. We saw records that showed patients had a medical review and a documented treatment plan in their medical records.

Staff were able to describe how they used hospital passports, facilitated increased visiting and used a dependency scoring tool to establish and provide support for people with a learning disability. We also saw these in use during our assessment. Records were complete, contemporaneous and stored securely.

Staff were provided with an enhanced level of support to ensure they could deliver the best care to their patients. Theatre staff were wearing their names and roles on hats. This helped patients and visitors to easily identify staff names and their role in the department.

We observed a patient arriving in theatre, the processes of reviewing consent, checking identification, World Health Organisation (WHO) checklist, and ‘sign out’ checks were completed in line with national guidance.

During our September 2024 assessment, we visited Ward 53. Audit data was displayed on a board, and we noted slightly lower than expected compliance with Malnutrition Universal Screening Tool (MUST). This is a screening tool used to identify and manage malnutrition in patients across various healthcare settings (score completed within 24 hours was 79%, and MUST score weekly was 73%). We also found a range of risk assessment documentation completed in line with trust policy.

People’s experience

People were aware of how to raise concerns and felt comfortable reporting safeguarding issues. Patients and their relatives told us they felt safe and protected from the risk of abuse.

Feedback from staff and leaders

Staff were knowledgeable about safeguarding patients from abuse and collaborated effectively with other agencies to ensure their protection. Staff were aware of the safeguarding processes and reported safeguarding concerns to the local authority if they were concerned about the risk of abuse. Staff had access to safeguarding resources and guidance on referring and escalating concerns and were provided with the relevant mandatory training so they could undertake this aspect of their role.

Processes

Safeguarding training compliance for staff working in surgical services were mostly achieving the trust target. Compliance with safeguarding adults level 2 training was 96% for nursing staff and 97% for medical staff. Compliance rates for level 3 adults safeguarding were lower with the nursing staff achieving 88% and the medical staff achieving 89%.

Compliance rates for level 2 children’s safeguarding was 94% and nursing staff and 93% for medical staff. The trust had designated safeguarding leads trained to level 4 in adults and children’s safeguarding and could be contacted by staff for additional support if required. Data showed 70% of medical staff had completed level 3 children safeguarding training.

People’s experience

People were aware of risks related to their care and felt risks were managed in a safe way. Patients told us they had their individual risks assessed upon admission. Patients who had an extended hospital stay told us their risk assessments were reviewed regularly.

Patients were given enough information from medical staff to be able to make informed decisions about their care and treatment. This included the risks associated with general anaesthetic and surgical procedures.

Feedback from staff and leaders

Staff worked well together to ensure the care delivered was in line with national guidance, risk assessed and tailored to meet individual need.

Processes

All pre-operative clinical tests were completed in line with National Institute for Health and Care Excellence guidelines

We saw evidence in notes that patients had a completed WHO surgical safety check list, as well as a sepsis screening tool. Other tools in use included but were not restricted to pressure area care, cannula and surgical site infections, and venous thromboembolism.

We saw documented evidence that NEWSs were recorded and acted upon when the clinical signs of deterioration were identified. We also saw records that showed patients had a medical review and a documented treatment plan.

We saw the use of ‘hospital passports’. A hospital passport is a document that provides essential information about a patient, particularly individuals with learning disabilities, autism, or complex health needs, to help healthcare professionals provide better care. One ward we visited had negotiated a 1-1 support from a patient’s community provider which was bringing enhanced care and one to one nursing support which reflected this patient individual needs.

We reviewed a sample of records in the wards we visited. Records showed a wide range of individual risk assessments was completed for all patients upon admission and were reviewed again for those who had an extended stay. Consent forms were found to be completed according to national guidance.

We saw evidence the hospital liaison team had supported staff and relatives with discussions around consent, advocacy and best interests for a patient who had a decision about resuscitation. We reviewed 2 sets of records for patients with learning disabilities, both sets were completed comprehensively, and all staff were able to access them.

People’s experience

Patients told us they were cared for in a clean environment by staff who had access to appropriate equipment.

Feedback from staff and leaders

The theatre recovery unit had 18 beds, including 2 for intensive recovery and 4 dedicated paediatric bays. There were 26 operating theatres in total. A refurbishment project was underway, being implemented in phases to minimise service disruption. The facility also included 2 robotic theatres, with plans to acquire a third. Robotic technology was used for urology, gynaecology, and general surgery.

There was a dedicated vascular theatre, with plans to develop a hybrid theatre to enhance vascular services. However, capital funding for this project had not yet been secured.

Staff had access to all necessary equipment, along with instructions and guidance for use. They applied their training in moving and handling to maintain both their own safety and that of patients.

Theatres were well-equipped, and staff could request loan equipment if something was not in stock. Staff reported that schedules were planned in advance, allowing them to ensure the required equipment was available when needed.

Observation

Storage space in the theatres was insufficient, but the trust had identified this issue and developed an action plan. This included converting a decontamination area into a storage facility. We saw 1 theatre was very cluttered, with a C-arm stored in the corner and 2 computers on wheels increasing clutter. A C-arm is a medical imaging device used in surgery and interventional procedures and is standard equipment in an orthopaedic theatre.

The main theatres suite had a significant amount of equipment lining the corridors and spaces outside theatres. Clean out of use equipment and was labelled clearly.

The malignant hyperthermia emergency trolley was located in theatre recovery. We found the fluid drawer open. This was escalated immediately, and staff took prompt action to address the issue. The trolley was included in routine safety checks and was generally monitored in line with guidance, though we noted a small number of missed checks over the past 6 months.

We also inspected 2 emergency trolleys on Ward 53. Checks for these trolleys were recorded electronically. One trolley had 13 missed checks over 6 months, while the enhanced care unit trolley had 5 missed checks in the same period. Both trolleys were fully stocked with in-date supplies and equipment.

The resuscitation trolleys on the surgical wards and surgical assessment unit were all checked in line with trust policy. At our March 2025 inspection we found an electronic audit process helped staff identify when checks were delayed or not carried out.

Staff had access to sufficient consumables and sterile instruments to deliver the service.

Processes

Clinical waste was stored and disposed of in line with national guidance. Staff understood their responsibility to separate and dispose of clinical waste. We observed the correct use of sharps containers and coloured laundry bags to distinguish between hazardous and non-hazardous waste.

We found evidence of electrical safety testing on equipment, including airflow systems in theatres and surgical wards, with all servicing up to date.

People’s experience

Patients told us they had their care needs met by staff who worked very hard. They felt the staff in their clinical areas were attentive and responded quickly when support was requested. Patients told us they received their medicines on time and had their pain well managed.

One patient said staff were working so hard they wished there was more off them. Another patient told us they experienced a long wait to be discharged.

Feedback from staff and leaders

All the staff we spoke with felt proud of their ability to work as a team but also as an effective member of the multidisciplinary team that provided care to surgical patients.

Staff felt supported by their immediate line managers. They told us they had good access to additional training provided by the practice development team and training could be influenced by their individual training needs. The practice development nurses also worked clinically to ensure they could provide hands on practical support to staff.

Some theatre staff had been given the opportunity to move into more senior roles and told us they felt very supported by their teams to do so.

The surgery group had taken many steps to ensure there were enough staff to deliver the service. These included actively recruiting to fill positions left vacant by retirement, reviewing staffing templates across the directorate, and evaluating staff deployment to ensure the most effective deployment of staff to meet service needs. When we inspected in March 2025, this work was still ongoing, but significant improvement was noted in theatres, on the wards, and in the SAU.

The SAU employed a GP liaison member of staff to help with patient flow and had also introduced the role of advanced clinical practitioners (ACPs). ACPs were highly trained healthcare professionals who had developed advanced clinical skills, knowledge, and decision-making abilities. They worked early, late, and twilight shifts. The trust was also supporting staff to train for these roles and was planning to introduce round-the-clock ACP cover in the SAU, with the full service expected to start in September 2025.

Ward 22 had a waiting list for nursing positions. Bank staff were in all clinical areas to cover for short-term sickness. Long-term sickness was managed according to the trust’s policy and staff were supported to return to work with support.

Staff said there were enough medical staff to provide cover for the service. During busy times, they sometimes felt under pressure but felt well supported by their peers and consultants. In the SAU, staff told us that during peak times, a doctor was usually available to see patients, but there was not always a suitable space for assessments. The leadership team was reviewing more pathways to free up space and relocate parts of the service to another area to increase capacity. Staff said staffing gaps were mostly covered by bank staff.

After CQC feedback in October 2024, surgery, including Ward 22, made several improvements. Weekly reviews helped track progress, and monthly meetings made sure staff were accountable. Patient feedback was collected 3 times a week, and staff checked care plans twice a week to improve records and prevent problems like pressure ulcers. These changes also helped train staff after the new electronic patient record system was introduced.

The trust told us about the risks associated with a national shortage of cardiothoracic surgeons. The trust had an action plan and mitigations to manage this risk while this national risk was addressed. This included the introduction of a cardiothoracic training fellowship.

There was a wide range of multidisciplinary staff providing support to the surgical service. This included but was not restricted to speech and language therapy, occupational therapists and physiotherapists.

Observation

The clinical areas we assessed had sufficient levels of staff to be able to deliver the service. Staff appeared to work well individually as well as collaboratively.

Processes

The trust held twice-daily safer staffing meetings to discuss staffing levels and any ongoing concerns. Staff told us that daily reviews took place to identify staffing gaps, and nursing staff were redeployed where possible to maintain safe staffing ratios. A safer staffing template was completed during these meetings and escalated as needed.

For medical staff, rota gaps were escalated by the clinical group manager of the day during regular site meetings. To cover gaps, the trust considered using bank and agency staff or, if necessary, asking consultants to cover unexpected resident doctor absences.

Areas with high vacancy rates, sickness, or staff turnover were reviewed by group management and through the trust’s performance framework. Data on staffing was monitored by the people committee and the trust board.

Neurosurgery on-call services were available 24 hours a day, including out-of-hours and weekends, with remote access to the trust’s systems. Trauma and orthopaedics also provided 24-hour on-call cover, with consultants staying on-site until 9pm and available overnight, while a resident doctor remained onsite throughout the night. Consultants were also available on weekends, and staff attended a post-night handover meeting.

Cardiac and thoracic consultants and resident doctors were on call overnight and at weekends. Theatres remained staffed overnight, with an anaesthetist available, supported by additional on-call staff if needed.

There were limited vacancies and low levels of sickness. Between March and August 2024, the average vacancy rate for consultants in all surgical specialities was 9%. Between March and August 2024, the average sickness rate for consultants from all surgical specialities was 2%.

Between March and August 2024, the average surgical specialties nursing staff rate was 5% against a trust target of 10%. Eighty-three newly qualified nurses started in September 2024 and 41 offers were made to start in January 2025. The trust had an international nurse recruitment programme which was planning to have 6 international nurses joining per month up to November 2024 across the trust.

The trust had recently recruited 11 anaesthetic consultants and employed 2 locum consultants covering maternity leave. The trust was achieving a 90% satisfaction rate in the General Medical Council National Education and Training Survey, compared to the 77% national average. Training numbers had also increased over 3 years which secured 6 additional posts.

The clinical support services group achieved 95% completion for electronic job planning. Weekly workforce discussions helped manage vacancies, which stood at 7.66 whole-time-equivalents (WTE) (or 9.66 WTE without locums).

Turnover for nursing staff in August 2024 was 6% against a trust target of 10%.

People's experience

Patients told us they were cared for by staff who wore appropriate personal protective equipment and washed their hands regularly. All patients were discharged with information to manage their surgical wounds and monitor for surgical site infections.

Feedback from staff and leaders

Staff were aware of the trust infection control policies and procedures and were able to tell us how they put this guidance into practice.

Observation

During our March 2025 assessment, we observed staff following the trust's infection prevention and control (IPC) guidance. Staff used appropriate protective equipment and washed their hands between patient contacts. Side rooms were available across the service for isolation when needed.

The trust conducted regular audits to monitor compliance with IPC standards. The IPC environmental audit average score was 95% to 98% for the areas we visited. We saw they were visibly clean and cubicle curtains being changed in accordance with the trust's routine curtain replacement programme.

Processes

The IPC team conducted regular audits, including quarterly hand hygiene observations, uniform compliance checks, sepsis audits, and environmental inspections. These audits also included equipment checks, and if any shortfalls were found, an action plan was produced to address them.

Catheter bundle compliance across surgical groups was routinely monitored, with an average score of 90 to 95%. Cannula care compliance was recorded at 94% for completed care elements. The trust operated an IPC dashboard, providing central oversight of IPC standards. Data from audits was reported to the infection prevention and control committee to support learning and improvement.

The trust routinely collected and monitored surgical site infection data across all disciplines. We received data for orthopaedics and cardiothoracics from the national surveillance programme for surgical site infections for June 2023 to June 2024. Data for hip and knee replacements across the trust (including the Hospital of St Cross) showed a rate of 0% in all months. Data for coronary artery bypass graft surgery showed rates ranged from 3% to 24%, with 6 of the 13 months falling between 12 and 18%, and 5 months from 3 to 9%.

There had been no MRSA bacteraemia reported by the trust in the 2024. In the months June to August 2024, there had been 12 hospital onset healthcare associated infections (7 E.Coli, 4 C.difficile and 1 MSSA), and 3 community onset healthcare associated infections (1 of each of E.Coli, C.difficile and MSSA).

Outcomes

There was an effective system to ensure water testing for legionella and pseudomonas bacteria. In areas we visited, we saw records of water testing completed regularly and including actions. The service conducted several audits including hand hygiene and surgical site infection audits.

People's experience

People told us they were given information, advice and support about their medicines including when there were changes made to their medicines by doctors and members of the pharmacy team.

One person told us `'Everything has been great, and I have had my pain relief when I asked for it''

However, there was a patient on ward 52 who told us they had not yet had their regular medications prescribed. They had been brought to a temporary space in the ward from the emergency department. We checked their medication chart and confirmed the patient had not had these medications yet, and also had not had low molecular weight heparin, although the venous thromboembolism risk assessment suggested this had been done. We escalated this to staff.

Feedback from staff and leaders

Staff told us there was a good pharmacy presence and the pharmacy department was available to support them with managing medicine processes, such as ordering and receiving medicines.

A new electronic prescribing medicine administration system had been in operation since June 2024. Staff said this was helpful and supportive to ensure the right medicine was administered to patients and it was easier to document why medicines had been omitted.

Staff told us they had access to relevant medicine policies, procedures and guidelines.

Staff told us that they had good access to pharmacy advice, emergency medicines and critical medicines out of hours.

Observation

Staff wore red aprons to indicate they were doing the medication round and to limit disturbances.

We observed members of the pharmacy team having discussions with people to check their medicine history was accurate and up to date. We observed clinical checks being undertaken by clinical pharmacists and updating patient medicine records as part of medicines reconciliation (the process of gathering a complete list of people's prescribed medicines). This was to ensure people did not go without medicines when admitted to the ward. Any discrepancies or medicine issues were successfully resolved and recorded to ensure the effective continuation of treatment.

Medicines for discharge were screened and checked for accuracy by clinical pharmacists.

Medicines storage was locked and secure with access only to authorised staff. The use of automated electronic medicine storage units were located on every unit to support ward staff to locate the correct medicine and ensure availability of medicines.

Resuscitation medicines required in an emergency were stored safely in tamper-evident trolleys which followed Resuscitation Council (UK) guidance. We observed that staff recorded safety checks to ensure the medicines were safe to use.

Medicines for refrigeration were stored securely with electronic central records available of maximum and minimum temperatures to ensure the medicines were stored safely.

Processes

The trust had a policy for the use and management of controlled drugs. This was dated and version controlled, but overdue review, with a review date of August 2023. We saw a copy of the trust adult antibiotic guideline, which was dated, version controlled, contained a reference to antibiotic stewardship, and was just slightly past the expiry date of 22 September 2024.

An annual medicines management and medicines optimisation audit was undertaken between February to May 2024 for the safe and secure handling of medicines. Recommendations were given to wards where actions and improvements were needed to ensure the safe management of medicines.

We reviewed multiple people's medicines administration records. They were well documented with route and time of administration, including recording a reason if a medicine was not given. Any missed doses were flagged as a reminder until the medicine was administered, or a reason documented. For example, 1 person had not had a dose of antibiotic administered. However, the record documented that it was `on hold while waiting for microbiology discussion'. Where a `PRN' (when required) medicine was administered staff recorded why it was needed. The information we looked at showed people were receiving their medicines as prescribed.

Weights of patients were recorded. However, they were not documented on the patients' electronic medicine administration records which would be useful to help support calculating weight-based medicines prescribing.

Venous thromboembolism assessments were mandatory and had been completed by the medical team.

Allergy status of patients was routinely recorded on all medicine records seen and were red flagged. This meant that allergies were highlighted, and medicines could be prescribed safely.

There were effective processes for reviewing antibiotic prescribing which included documenting a reason for the antibiotic choice. A review date at 48 to 72 hours after initiation of treatment was highlighted on medicine charts.

Controlled drugs (CDs, medicines requiring more control due to their potential for abuse) were stored safely and securely with access restricted to authorised staff. Checks were undertaken and recorded by 2 staff daily. Checks of CDs showed that they were within date and stock balances were accurate.

There was a clear process for managing and reporting any errors or incidents involving medicines. Staff were able to talk through the process that would be followed if this occurred.

Medicines management compliance was audited, data showed 12 wards had full compliance, 3 had partial compliance and 4 had low compliance.

The CD audit in May 2024 showed a range of compliance between 63% and 94% against a trust target of 95%.

When we inspected in 2024, we asked to see records about how medicines were checked over 3 months. A new computer system started in June 2024, so the new records were not available. However, our March 2025 inspection saw improvements to the EPR medicines reconciliation data and audit processes. Whilst the EPR data was still going through a revalidation process, there was a manual compliance process running alongside in real time which was monitored by a clinical lead.