University Hospital

On this page

• 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 looked for evidence that people and communities had the best possible outcomes because their needs were assessed. We checked that people’s care, support and treatment reflected these needs and any protected equality characteristics, ensuring people were at the centre of their care. We also looked for evidence that leaders instilled a culture of improvement, where understanding current outcomes and exploring best practice was part of their everyday work.

This is the first time we have inspected this service. At this inspection we rated the service as good. This meant people’s care and treatment was delivered in line with evidence-based practice. Staff and teams worked well together to ensure people benefited from effective care and treatment. People’s outcomes were monitored and where required actions taken to improve their experience. Consent was managed in accordance with legal requirements.

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 service made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

People were involved in the assessment of their needs, and support was provided where needed to maximise their involvement. Staff ensured patients were able to share their individual needs when completing the pre-assessment and admission process.

The assessments completed by staff were comprehensive and ensured they assessed the communication needs of patients so care and treatment could be maximised whilst they were admitted to the service.

Assessments were up-to-date and staff understood the needs of the women they were caring for. Staff told us most of the women only required short admissions, however for those patients who remained on the ward for longer, staff regularly reviewed the assessments to ensure they were meeting the needs for the patients they were caring for.

The service did not always plan and deliver people’s care in line with legislation and current evidence-based good practice and standards. However, staff included patients and what was important and mattered to them.

The service implemented trust systems to try and ensure staff followed up-to-date policies to plan and deliver high quality care according to evidence-based practice and national guidance. Care was mostly provided in line with national clinical guidelines and quality standards set by Royal Colleges and the National Institute for Health and Care Excellence. The service only completed termination of pregnancy under specific circumstances. Staff told us they had a good working relationship with services where women could seek termination of pregnancy at earlier stages in their pregnancy. Staff ensured all relevant guidance and legislation was followed.

Staff mostly completed assessments for each patient using recognised tools which were evidence-based. This included the assessment of patient’s nutrition and hydration status. Staff completed malnutrition risk assessments for patients and where any concerns were identified, these were escalated and patients were referred to specialists for their input. However, we observed patients did not always have their hydration needs met. Patients returned from theatre with catheters or drains in place, however fluid balance documents were not always completed. We found in 1 set of patient records, the fluid balance only had the drain output measured with no input or other output fluids recorded. In another patient’s record we found the patient had returned with intravenous fluids in place from theatre but there was no fluid balance in place at all. This practice was not in line with recommended national evidence-based practice which identified patients with intravenous fluids should have fluid balance charts maintained. We raised this with staff at the time due to our concern there was no oversight of the patient’s fluid balance where the need to do so was identified. We requested audit information in relation to fluid balance chart completion. The information shared between September and November 2025, identified that the service improved their compliance from 80% to 100%. Earlier audits identified a theme around visibility of patients who required monitoring which was impacting on fluid balance completion. A ‘stop the clock’ huddle was introduced on Ward 23 which gave staff the opportunity to ensure all patients had the appropriate care needs met which included ensuring fluid balance monitoring was completed.

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

When people received care and treatment from members of the multidisciplinary team (MDT) it was co-ordinated and effective. All relevant staff, teams and services were involved in assessing, planning and delivering patient care and treatment and staff worked collaboratively to understand and meet patient needs. Staff told us they worked well with all members of the MDT and regularly held meetings to discuss patients who had complex requirements. We also observed all staff working well together to ensure the holistic needs of a patient were met.

Staff from Ward 23 told us they worked well with staff from other surgical wards. Where patients who were not gynaecology patients were admitted, they worked together to ensure the needs of the patients were met. They also ensured speciality transfers were completed quickly and collaboratively.

During our onsite inspection, we observed staff within theatres working effectively together with clear direction from the lead surgeon and scrub nurse and clear communication with each other. This enabled the operation to run smoothly and ensured all essential safety steps were completed and recorded.

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, reduce their future needs for care and support.

People were encouraged and supported to make healthier choices to help promote and maintain their health and wellbeing. Staff on Ward 23 identified many examples of issues specifically relating to women’s health where they were able to provide information to help patients make healthier choices. We observed a wide range of leaflets available for women who wanted to seek further information about a range of specific health related concerns.

Services focused on identifying risks to people’s health and wellbeing early and how they could support people to prevent deterioration. During pre-assessment of patients who required surgery, staff discussed healthier lifestyle choices with them. They completed ‘pre-hab’ to ensure they were prepared for the post-surgery recovery. This involved providing activities for patients to practice which would help them after the procedure but also specific lifestyle advice which will improve their recovery.

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

People who used the services expected to experience positive outcomes which were in line with the expectations set out in legislation, standards and evidence-based clinical guidance. The service participated in many national and local audits including but not limited to the National Ovarian Cancer Audit, National Confidential Enquiry into Patient Outcome and Death (NCEPOD) Endometriosis audit, audit of compliance with nausea and vomiting in pregnancy/hyperemesis local guidelines and the Linzagolix service evaluation. Outcomes appeared mostly positive and showed patients received a good standard of care. Where areas for improvement were identified, staff completed action plans and evidence of reauditing was shared to follow up on any improvements made.

Staff told us there had been a surprise when the results of the National Oversight Framework was shared which unfortunately showed the trust were ranked 132 out of 134 trusts. Although the result took into consideration all services provided by the trust, staff within Gynaecology had taken this extremely seriously. Senior members of the service continued to monitor the Gynaecology cancer pathways and outcomes to identify if any further improvements could be made. Senior leaders told us the most recent update identified the trust as a whole had improved and were the 3rd most improved trust across the country for cancer. They were now ranked 96 out of 134.

Staff told us they were reviewing some of their pathways to ensure the service was in line with the Getting it Right First Time (GIRFT) programme. They were working on the principle that women should expect timely and effective investigations, treatment and outcomes, wherever care is delivered.

There were effective approaches to monitor people’s care and treatment. The service had a gynaecology dashboard in place which captured all key information, statistics and performance data for the service. In addition to this, there were regular Quality Improvement and Patient Safety meetings which had regular agenda items for monitoring patient outcomes, such as mortality reviews.

The service told people about their rights around consent and respected these when delivering person-centred care and treatment.

Staff understood the importance of ensuring people fully understood what they were consenting to and the importance of obtaining consent before they delivered care and treatment. All staff were aware of gaining consent from patients prior to completing any treatment or procedure. This also involved implied consent from patients when undertaking activities such as monitoring a patient’s blood pressure. Where more formal consent was required to undertake clinical procedures, this was completed in accordance with policy and legislation. We reviewed consent forms which had been completed and had no concerns over the consent process. We requested audit information in relation to consent procedures. Due to the implementation of their electronic records system, there had not been an audit completed since 2022. However, an audit was due to be completed as part of 2025/2026 audit programme.

There were effective practices to ensure patients understood the care and treatment being provided. This helped patients to make informed decisions about their care. Staff ensured patients were provided enough information to make informed decisions and give informed consent. Patients we spoke with told us they received enough information to give their consent for procedures.

Patients’ capacity and ability to consent was considered. Staff understood the relevant consent and decision-making requirements of legislation and guidance, including the Mental Health Act, Mental Capacity Act 2005 and the Children Acts 1989 and 2004 and they knew who to contact for advice. Staff were able to describe and knew how to access the trust’s policy and get accurate advice on Mental Capacity Act and Deprivation of Liberty Safeguards. Staff understood Gillick Competence and Fraser Guidelines and supported young people to make decisions about their care.