University Hospital

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

We looked for evidence that people and communities were always at the centre of how care was planned and delivered. We checked that the health and care needs of people and communities were understood, and they were actively involved in planning care that met these needs. We also looked for evidence that people could access care in ways that met their personal circumstances and protected equality characteristics.

This is the first time we have inspected this service. At this inspection we rated the service as good. This meant people’s needs were met through good organisation and delivery. People were able to access the care, support and treatment they needed, when they needed it. People were at the centre of their care and treatment choices and staff provided information in formats which met the needs of the patient.

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 service did not ensure all staff have completed training to enable them to recognise and respond to the additional needs of patients. Despite this, staff always 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.

People’s care plans reflected their physical, mental, emotional and social needs. Patient records were mostly completed electronically. Staff selected which care plans were required for each patient and then regularly reviewed and completed progress notes. We reviewed 6 sets of records and found these reflected the patients’ needs.

Staff regularly reviewed people’s needs and updated records when things had changed. Most staff had received training on recognising and responding to patients with learning disabilities and autism. The trust as a whole rolled out Oliver McGowan training to all staff as part of the national roll out. The trust were set the target to have 63.3% of staff compliant by the end of March 2026. At the time of our inspection, staff groups within the service were above this with the exception of clinical administrative staff.

Most staff had not completed training on dementia awareness. The training in relation to mental health needs and dementia awareness was identified as a role specific development requirement and therefore the uptake in this training was a lot lower. Dementia awareness training ranged from 2.1% to 48% of clinical staff completing this training and mental health awareness ranged from 2.7% to 60% of staff completing this training.

People received the most appropriate care and treatment for them as the service made reasonable adjustments where necessary. When patients had communication issues as a result of a disability or sensory loss, staff took action to address these issues and provided the information in ways which met their needs.

People understood their condition, care and treatment options. Patients told us staff discussed their care and treatment with them and regularly updated them on their progress. We observed staff discussing patients medical conditions with them in ways which was easy for them to understand and in sensitive ways. Staff regularly updated patients on their progress and discussed discharge plans.

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.

People received care and treatment from services that understood the diverse health and social care needs of their local communities. Staff from the service had been involved in the development of ‘Health in the High Street’ which aimed to make healthcare, more specifically gynaecology care more accessible for patients, especially those from areas of deprivation. The location was due to open imminently which all staff who spoke with us were very positive about. They were already in discussions around how this could be replicated in other regions where deprivation and other health inequalities were identified. Leaders had identified there were local maternity hubs across the system and were looking at how they could pair with them to deliver gynaecology care.

Leaders told us how they were working closely with other partners within the region to ensure women received joined up care which was also flexible to their needs. An example of this was looking at how women experiencing issues such as post-menopausal bleeding could be cared for within the community rather than through the clinics provided by the hospital.

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

Staff provided people with information which was tailored to their needs. Where patients were known to have an impairment, an alert was placed on their records which supported staff to meets communication needs.

People expected information to be tailored to individual needs. We observed a number of patient information leaflets which were in a range of languages other than English and were identified to meet the needs of the local population who used the service. Staff told us information could also be provided in Braille for patients who required this. Staff also told us they had access to a wide range of communication aids for patients.

Staff were aware of the process for requesting interpretation and signers for people who required the service. In addition to this, the service had access to portable electronic devices which provided live interaction with human interpreters.

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

People knew how to give feedback about their experiences including how to raise complaints or concerns. The service clearly displayed information about how to raise a concern in patient areas. Patients told us they felt comfortable raising any issues with the staff caring for them at the time.

People felt their complaints and concerns would be thoroughly investigated. They felt they would receive a response in a timely manner, and that it would be dealt with in an open and transparent way with no repercussions. Managers investigated complaints and identified themes. Staff knew how to acknowledge complaints and patients received feedback from managers after the investigation into their complaint. There were 7 open formal complaints for the service and 4 open cases with the Patient Advice and Liaison Service received between October and November 2025. The main themes identified was in relation to clinical treatment, communication, access to treatment and appointments. At the time of our inspection, the service had received 1 complaint from the Parliamentary and Health Service Ombudsmen which they were still reviewing.

Learning from complaints and concerns was seen as an opportunity for improvement and staff gave examples of how they had incorporated learning into daily practice.

The service was not always meeting targets to provide people with timely emergency and elective care. The service was still working to reduce the numbers of patients waiting for their procedures.

People could access the urgent care, treatment and support when they needed to and in a way that worked for them. The service had an Emergency Gynaecology Unit (EGU) which was open 24 hours a day, 7 days a week. The EGU received direct attendances from women who were experiencing gynaecological concerns and/or women who were pregnant up until 20 weeks. Between June and November 2025, there were 5,136 patients who attended EGU. The large proportion of attendances related to women who had concerns with their pregnancy (below 20 weeks) and abdominal pain.

The service monitored Emergency Gynaecology Unit (EGU) performance against emergency care access standards. Staff reported they generally managed to triage women within the 15‑minute target, but overall performance varied due to the complexity and sensitivity of patients’ situations. Between 21 September and 30 November 2025, triage performance ranged from 73.7% (highest) to 40.7% (lowest), with the lowest recorded on 30 November. At the time of inspection, triage was at 56.9%, with signs of improvement. Despite fluctuations in triage times, the service consistently achieved the 4‑hour standard internal target of 78% throughout the monitored period. Staff explained meeting the targets was largely impacted by the sensitive nature of why the women were attending and the need for staff to ensure they were meeting the needs of these women, rather than what was described as “insensitively” moving on to the next patient.

In addition to the above standards, the service monitored the EGU against the 12 hour total wait time from decision to admit them to a ward bed. The service was achieving their internal target of below 8% of admissions reaching this total wait. Information between September and November 2025 showed the service was mostly recording no patients waiting for this long, with 0.12% of patients awaiting admission in November 2025 waiting for over 12 hours.

Within the EGU, the service monitored the percentage of patients who were seen by a doctor within 60 minutes of arrival. Staff told us this could be impacted at certain times of the day due to the requirements for covering other areas. Information provided by the trust showed between the period of 21 September and 30 November 2025, performance against this ranged between 35.3% on the 21 September to 11.6% on the 30 November 2025. At the time of our inspection performance had improved and 22.6% of patients were seen by a doctor within 60 minutes of arriving at the EGU.

The EGU provided emergency gynaecology care to adult women and to young girls who were experiencing concerns with their pregnancy below 20 weeks. All other gynaecology concerns within young girls was managed whilst they were admitted on the paediatric wards. Information showed between June and November 2025, there were 70 attendances at the EGU by young girls under 18 years old.

Managers monitored the waiting times and tried to ensure people could access services in a timely manner. Information shared showed at the time of our inspection, there was around 6,736 gynaecology patients on the waiting lists. Elective performance for the service was recorded at 51.4% against the 18 weeks constitutional standard. This was above the current reported average of 47.4%. The service did not have any patients waiting over 78 weeks. Staff believed there was a possibility of no patients waiting over 65 weeks in December 2025, however members of the senior leadership team were aware there would be 31 patients who would move into this list at the beginning of January 2026. At the time of the inspection, the service had 325 patients waiting over 52 weeks.

Managers monitored the readmission rate for the service. This applied to those patients who had undergone surgery and required readmitting. Between June and November 2025 there were 14 patients who were readmitted. No additional information around the themes for readmission were noted on the information provided, however staff told us patients occasionally returned following surgery due to pain and infection.

Staff told us cancer waiting times and performance was improving and the trust had been recognised as the 3rd most improved in the most recent review, of which the gynaecology service was largely involved in. The trust was currently performing at 80.7% in the faster diagnosis standard against a trust target of 78%. Current performance for treatment within 31 days was recorded at 100% compliance against a trust target of 96%. However, the current performance for combined treatment at 62 days of GP referral was 50%. Additional information highlighted the trust were currently providing mutual aid to another trust which had impacted their performance. The service provided 97.3% of patients with their first urgent appointment within 14 days of a GP referral where cancer was suspected. Staff told us this was no longer a key performance indicator; however this was better than the 93% target which was previously in place.

Staff told us on the day cancellations were minimal and where possible, would be rescheduled within the 28 days. However, staff were aware of a significant number of did not attend (DNA) appointments. Staff told us patients received messages to make them aware of their appointments as well as some staff also calling patients. However, this did not always solve the issue, but had made some improvements to the DNA rate. Between June and November 2025, out of 12,788 appointments, there were 1,169 DNAs which accounted for 8.4% of the appointments. Staff also followed up with patients after their missed appointments and rebooked if required.

Managers and staff worked hard to make sure patients did not stay longer than they needed to. Staff told us the length of stay (LOS) on the ward was really low including patients who had undergone major gynaecological surgery only requiring a hospital stay for 2 or 3 days. Staff told us this had been as a result of the ‘prehab’ which patients underwent before attending their admissions. Information received after the inspection showed the average LOS in November for gynaecology patients was 1.2 days. The average LOS for surgical outlier patients (patients on the ward who were admitted for non-gynaecology reasons) was 3.2 days. Staff told us they did not admit any medical patients on to the ward. This had been as a result of reducing the number of beds on the ward. Only other surgical patients were admitted onto the ward which had been an agreement from senior leaders.

Due to the demands on the service, each bay on the ward had an additional bed, referred to as a ‘boarded space’. Staff told us this additional bed would not be present overnight as they would ensure patients were moved into a designated bed space. However, information requested after the inspection showed between June and November 2025 36 patients remained in the boarded space overnight. The longest time a patient remained in a boarded space was 168 hours. The service had a standard operating procedure for these circumstances to ensure patient safety was maintained.

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.

People’s care, treatment and support promoted equality, removed barriers or delays and protected their rights. Staff were aware of the local population which they served and were aware of the inequalities and marginalised groups within this population. They had worked collectively with patient representatives to ensure the care provided to patients met the needs of all, especially those likely to experience inequality.

Leaders and staff were alert to discrimination and inequality that could disadvantage different groups using their service and proactively sought out ways to address any barriers and improve people’s experiences. Staff told us the Health in the High Street model had been devised with the inequalities concerns in mind. Staff discussed many examples where women had not attended appointments due to their inability to afford transportation to the hospital. Staff identified having locations in more accessible areas would ensure those women would be able to access the care required. Staff told us how they would like to see this replicated further due to other areas having significant challenges.

At the time of our inspection, staff were not aware of any complaints or concerns raised in relation to discrimination experienced by the patients they cared for.

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.

People were supported to make informed choices about their care and plan their future care while they had the capacity to do so. Staff told us they provided care and treatment to women who had a diagnosis of gynaecological cancer. Some patients returned to the ward for ongoing care and treatment and as part of this, staff helped them to make any advanced plans about their care which included those women who were given a terminal diagnosis. There were specialist nurses who were also able to support patients with any specific care planning for the future.

When people wanted to express their wishes about cardiopulmonary resuscitation, they were supported to do so and were able to change their mind if they wished. The service used Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) forms to compliment any advanced care plans completed. At the time of our inspection, we did not observe any patients who held a ReSPECT form and were therefore unable to review the quality of these forms.