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

We looked for evidence that safety was a priority for everyone, and leaders embedded a culture of openness and collaboration. We checked that people were safe and protected from bullying, harassment, avoidable harm, neglect, abuse and discrimination. We also checked people’s liberty was protected where this was in their best interests and in line with legislation.

This was the first time we have inspected this service. At this inspection we rated the service as good. This meant people were safe and protected from avoidable harm. There was a positive and proactive culture around safety, patients were protected from the risk of bullying, harassment, abuse, discrimination and avoidable harm and neglect. Staffing levels did not always ensure the service met the needs of people; staff understood risk factors, however these were not always assessed in line with policy. They ensured people were protected from the risk of infection. Medicines were managed in a safe way which met people’s needs, and the service was modernising the location to ensure people were cared for in a safe environment.

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.

The service had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Safety was a top priority that involved everyone. All staff knew what incidents to report and how to report them. Staff raised concerns and reported incidents and near misses in line with the services policy. Staff spoke confidently about the incident reporting policy and what incidents to report. Staff in the Emergency Gynaecology Unit (EGU) told us they regularly reported incidents around delays in triage and meeting the 4 hour target, extra scan clinics and delays with blood results. This information supported business cases submitted by the service to improve the service.

Data from the service showed there were 109 incidents reported between 1 June and 5 December 2025. Most of these incidents were graded as no harm (80 incidents). The service had reported 1 serious harm during this period, and this occurred in the EGU. Details from the learning from patient safety events system showed this was related to a missed opportunity to diagnose an ectopic pregnancy earlier.

Staff understood the duty of candour. Staff were generally open and transparent in their approach to incidents. Where things went wrong, staff apologised and provided a full explanation.

Lessons were learnt from safety incidents raised. Staff were able to share examples of learning which had taken place as a result of incidents that had been raised previously. Staff also discussed changes which were implemented as a result of learning from incidents and safety alerts received.

Learning from patient safety incidents was a regular agenda item on the Quality Improvement and Patient Safety (QIPS) meetings. Specific issues which were discussed were serious incidents and mortality reviews.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. Staff made sure there was continuity of care, including when people moved between different services.

Safety and continuity of care was a priority throughout people’s care journey. This happened through a collaborative, joined up approach to safety which involved staff and care partners. The service had worked collaboratively with oncology services to ensure the care women required for gynaecological cancers was always joined up and effective. Staff told us their links with both internal and external partners for the pathway were strong.

There was a clear pathway in place for young girls who experienced gynaecology health concerns. Patients who were under the age of 18 and were pregnant received care and treatment on the EGU. Any young girl under the age of 16 years old who had suspected gynaecology issues was seen by the gynaecology team in the children’s unit and then admitted to the children’s ward if required. Young girls aged between 16 and 17 years old were reviewed in EGU for any emergency gynaecology concerns and were then given the option of which ward they wanted to be admitted to if an admission was required.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff 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.

There was a strong understanding of safeguarding and how to take appropriate action. Staff were aware of the relevant safeguarding policies, which were based on national guidance and legislation and followed them if they had concerns.

There was a commitment to taking immediate action to keep people safe from abuse and neglect, which included working with partners. Staff were aware of the trust safeguarding team and were complimentary about the support they provided in the event of identifying a safeguarding concern.

Staff received safeguarding training specific to their role on how to recognise and report abuse. Staff were required to complete PREVENT training along with levels 1 to 3 in both adult and children safeguarding. Most staff had completed all required training; however, data showed all modules were below the 95% trust target for medical staff across the obstetrics and gynaecology service (ranging between 75% and 88.9% compliance). In addition to this, nursing staff on Ward 23 were recorded below the trust target for level 3 adult safeguarding (compliance was recorded at 71.4%). It was also recorded that gynaecology specialist nurses were below trust target for compliance with level 3 children’s safeguarding. Although not all staff had completed the required safeguarding training, this did not appear to impact staff knowledge on what constituted as abuse and neglect and how to act on these concerns.

Staff told us they rarely had the need to raise safeguarding alerts themselves. However, staff were able to discuss situations which had occurred where they had needed to raise concerns. Staff had a comprehensive knowledge about Female Genital Mutilation and actions they were required to take if they identified any concerns in relation to this; however, staff told us this was uncommon among the local patient population.

People were supported to understand their rights, including their human rights, under the Mental Capacity Act 2005 and their rights under the Equality Act 2010. Staff were aware of the Mental Capacity Act 2005 and completed patient assessments when concerns were identified about their capacity to make decisions about their care. There was an understanding of the Deprivation of Liberty Safeguards, and staff only used this in the best interests of their patients.

The service tried to work with people to understand and manage risks by thinking holistically. However, there were areas of risk including sepsis management, VTE assessment and fluid balance monitoring which required continuous improvements to be embedded.

Risks were mostly assessed and people (where appropriate) and staff understood them. Staff mostly completed comprehensive risk assessments for each patient on admission using recognised tools, and reviewed them regularly.

Staff used a nationally recognised tool to identify deteriorating patients and escalated them appropriately. The service used the National Early Warning Score (NEWS2) for the detection and response of deteriorating patients. We reviewed 6 complete sets of patient records and found most observations were completed according to the frequency required for the patient and escalated according to policy. However, there were examples where staff hadn’t followed trust policy. One patient was transferred to Ward 23 with a respiratory infection and had not had observations recorded for almost 9 hours. The patient had been transferred to the ward due to becoming unwell whilst awaiting their medication to take home. During the factual accuracy process, the service raised it was their clinical process for patients to be on 12 hourly observations. However, at the time of the inspection, there was no indication the patient was on 12 hourly observations, and staff did not share this with the inspection team. Another patient recorded a NEWS2 of 3 which was in relation to their low blood pressure. We did not observe any evidence of escalation for this; however staff closely monitored the patient’s blood pressure after this, which continued to record a NEWS2 score of 3. Staff told us the trust were piloting a new electronic system which would automatically escalate observations that were outside normal parameters. At this time, all escalations were reliant on staff members verbally escalating any potential deterioration concerns. The service audited their observations being performed on time, no additional aspects were reviewed, for example whether, escalation was completed in line with trust policy. The results of the audit showed 100% compliance with this in November and September 2025. In October 2025, the compliance dropped to 60%. The results of this were shared and discussed amongst all teams. Feedback from this identified staff were not aware of a functionality which identified when observations were due within the electronic tool they used to monitor observations.

Staff completed risk assessments for each patient on admission, using recognised tools, and reviewed these regularly, including after any incidents. These risk assessments included, but were not limited to, a patient’s risk of skin damage, malnutrition risks, manual handling, venous thromboembolism (VTE – blood clots) risk, and falls risk. We reviewed the risk assessments completed for 6 patients and found most patients had all their risk assessments completed within the expected timeframe and where action was required, staff had taken this. However, there were inconsistencies in relation to VTE assessments and the provision of prophylactic medication and devices. We found 1 patient had not had their VTE risk assessment completed despite being admitted for over 24 hours. In addition to this, we found patients wearing anti-embolism stockings which were not prescribed. We requested audit information for VTE assessments by the service. Information received identified the service did not audit their own VTE assessments. However, information was captured by central reporting and combined data with children’s and maternity services in the group. Data showed 62% of patients in the Women and Children’s group were assessed within 14 hours of admission in November 2025. This was an improvement from 55.9% in September 2025.

We observed a ‘focus on improvement’ board on Ward 23 around the completion of malnutrition risk assessments and the intention to drive improvement among this. We found malnutrition risk assessments were completed in all records we reviewed.

Staff were aware of sepsis and told us they completed sepsis screening for patients when concerns were raised. Staff spoke confidently about the recognition and management of sepsis. At the time of our inspection, we did not identify any patients who were showing signs of potential sepsis. We requested audit information around sepsis performance for the service, this showed between September to December 2025, 3 patients were included in this audit, however 1 patient was later identified not to be meeting the criteria. Out of the 2 remaining patients, only 1 patient (50%) was recorded to be compliant with the sepsis bundle. Immediate feedback was provided to the service on areas where improvement was required.

People were informed about any risks and how to keep themselves safe. The trust as a whole had introduced call for concern where patients and/or their families could request an urgent review under Martha’s Rule. We observed information around the ward area providing patients and visitors with this information. Staff from the service monitored the impact of this and reported at governance meetings on any calls made in relation to their patients. This was also another area of the focus board for Ward 23 where improvements around the implementation of this were identified.

There was good compliance with safety checks in the operating theatres. We observed staff completing the World Health Organisation (WHO) surgical safety checklist. Information received after the inspection showed the service had been constantly achieving above 99% compliance with the WHO safer surgery checklist between September and November 2025.

Patients who returned from theatre did not always have fluid balance charts in place. We reviewed 6 complete sets of notes and found 4 patients who had been to theatre and returned with either intravenous fluids or drains in place. These patients did not have a fluid balance chart completed despite them needing close monitoring of their fluid input and output. We shared these concerns with the staff and senior leadership at the time. We requested audit information from the service after the inspection and this showed compliance with fluid balance completion rose from 80% in September 2025 to 100% in November 2025. Feedback from an earlier audit included there being a lack of visibility of patients requiring fluid monitoring. To overcome this issue, staff had implemented a visual control board which identified which patients required fluid monitoring, as well as ‘stop the clock’ huddles twice a day to ensure all patients were having their needs met. Although improvements were identified between this time, information provided showed monitoring of this would continue until improvements were embedded.

Staff told us they rarely had patients admitted who were identified as a mental health risk. However, the trust was supported by a local mental health service who would review patients if risks were identified.

The service detected and controlled potential risks in the care environment. Staff made sure equipment, facilities and technology supported the delivery of safe care.

There were processes to ensure equipment and the environment were well maintained and safely met the needs of the patients admitted to the area.

The service had suitable facilities to meet the needs of women. This included dedicated scanning rooms within both the EGU and the clinic setting. There were also designated clinic rooms available for hysteroscopy and colposcopy clinics.

The process was effective for ensuring emergency equipment on the ward and in theatres were well maintained and ready for use. We found the resuscitation trolley had a tamperproof mechanism in place and all items checked were found to be in date. The anaesthetic trolleys and machines were observed to have daily checks completed by staff.

We reviewed a selection of clinical consumable items including cannulas, dressings, airways, suction tubing, syringes and blood sample bottles and found all items were in date. We also reviewed 5 items of equipment and found their electrical testing and services had been completed.

Staff disposed of clinical waste safely. We observed staff correctly segregating clinical and domestic waste. Waste bins were enclosed and foot operated. Sharps bins were correctly assembled and below the fill line. The management and disposal of sharps and waste was completed in accordance with the trust policy.

The service did not always ensure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. However, staff worked together well to provide safe care that met people’s individual needs.

Staff told us there were appropriate staffing levels and skill mix to make sure people received consistently safe, good quality care which met their needs. However, information received after the inspection showed there were high levels of vacancies compared to the trust rate of 10%. Nursing staff had the highest vacancy rate recorded at 24.5%(this was noted to be an 8.64 whole time equivalent in staff members). This vacancy was related to EGU and gynaecology clinics. Despite this, during our onsite inspection nursing staff within the ward, EGU and clinic areas reported staffing was stable and there were minimal vacancies within these areas.

Staff told us recruitment was ongoing for all vacancies. Despite these vacancies, staff did not raise any specific concerns relating to pressures felt from being understaffed. Actual staffing mostly met the planned staffing for the service.

Vacancy rates within medical staffing across gynaecology and obstetrics were recorded as 21.3% (this was noted to be a 15.24 whole time equivalent in staff members). No additional information was shared relating to what specific levels of doctor this related to; however, staff told us there had been an increase in consultants within this service. Following a previous inspection of all surgical services in September 2024 and March 2025 it was noted at the time there was challenges within the medical workforce which included amongst the consultant body and also the resident doctors. At the time, doctors in training had raised concerns with us about the demand placed on them to cover the gynaecology services with minimal senior oversight, especially out of hours. During this inspection, we were aware that despite the number of consultants being increased, there were still some sub-specialities (endometriosis and urogynaecology) which were deemed vulnerable as there was only 1 consultant who covered that position. We were also told there were still concerns around the lack of senior cover support during the night shifts due to the sharing of resources with obstetrics. However, all staff told us they had no concerns in escalating any issues to the onsite senior doctors or the consultant on call if required.

Managers did not limit their use of bank staff within the service. We requested information after the inspection on the number of bank shifts for this service alone. However, information shared after the inspection showed between September and November 2025, 230 nursing shifts and 321 medical shifts for the whole Women and Children’s clinical group were covered by bank staff. The medical staffing shifts did not include the additional shifts required to cover industrial action during November 2025. During this period, no agency staff were used to cover any nursing or medical staffing shifts. However, the service did use agency staff in September and October 2025 to support their scanning clinics. Staff also told us bank staff had been used to support the night shift within EGU; however, the service had been given approval to convert this into a full-time position and recruitment was ongoing.

The service had low levels of sickness and turnover. Current sickness rate for the whole of the service was 2.09%. However, the additional clinical services recorded a higher sickness rate of 7.06%. The current turnover for the service was 3 staff members. Staff told us staff usually left the service to follow promotional opportunities with many staff having been in the service for a substantial number of years and likened it to a family environment.

Staff received appropriate training to their role. Staff were required to complete and update mandatory training which was comprehensive and met the needs of the patients and staff. Staff we spoke with told us they had completed their training and managers told us there were processes for monitoring compliance with mandatory training. Data showed overall compliance for the service was 86.2% which was below the trust target of 95%. There were some topics which recorded 95% compliance or above, for example fire safety and thromboprophylaxis. However, the majority of topics were below the trusts 95% target. This included obtaining blood samples which recorded the lowest compliance of 61.1%, infection control non-clinical 83.3% and moving and handling with 84.3% compliance. Basic life support was another training module which was below the trust target of compliance at 90.7%. The medical staff across the obstetric and gynaecology service recorded the lowest level of compliance for basic life support training at 75.9% compliance. The training information had other levels of life support training on there; however, no staff members were recorded to have completed this. No additional information was shared at the time of the inspection or during factual accuracy on how the service intended to improve mandatory training compliance. However, the inspection team did not specifically request this at the time.

Staff received the support they needed to deliver safe care. Staff underwent appraisals in their roles. Data showed current compliance with appraisals for nursing and additional clinical and administrative staff was 85.3%. Further information showed 90.9% of the medical staff had received their medical appraisals in line with professional body requirements.

The service mostly assessed and managed the risk of infection. Staff detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Staff protected patients from the risk of infection by maintaining the environment and equipment to ensure they remained visibly clean and tidy. We observed all areas we visited as visibly clean and tidy and saw domestic staff cleaning areas whilst we were present. Staff members cleaned equipment after patient contact to reduce the risk of cross infection.

The service had an approach for assessing and managing the risk of infection. Ward 23 had 4 side rooms available for patients who were confirmed or suspected to have an infection or colonisation (the presence of microbes without causing an illness or injury).

Staff told us the service had recorded no infections for any alert organism within the last 3 months. However, information received after the inspection identified a current review that was being completed by the service in relation to a bacteraemia that was recorded as a result of staff failing to screen a patient for MRSA despite identifying significant risk factors. As a result of the learning from this incident, the service were introducing universal MRSA screening on admission.

The service completed audits to provide assurance that patients were provided with safe care in line with infection prevention and control standards. Staff completed national cleaning audits monthly, results were recorded between 97.8% and 98.6% which was above the identified target score of 95% for the identified risk area being audited. Hand hygiene audits were also completed within the service. The audits for EGU found staff were 100% compliant with hand hygiene. The audits for Ward 23 found compliance ranged between 42.9% in September 2025 and 100% compliance in October 2025. Feedback was provided to the area and close monitoring continued.

The hospital policy required staff to risk assess their areas for when masks should be worn, and we observed areas within the hospital which required staff to wear masks due to respiratory infections. The policy and risk assessments around mask usage were vague in their recommendations. The practice of staff wearing masks due to their own preference appeared confusing for patients and visitors on the ward areas and led to confusion over what the level of infection risk was.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

The services approach to medicines reflected current and relevant best practice, professional guidance and relevant legislation. Medicines storage was locked and secure with access only to authorised staff in most areas. Emergency medicines were stored in tamper evident sealed boxes with the expiry date visible on the outer box. All oxygen cylinders seen were within date and stored securely.

Medicine room storage and refrigerator temperatures were monitored. Medicines for refrigeration were stored securely with records available of maximum and minimum temperatures to ensure the medicines were stored safely. Staff informed pharmacy if temperatures were out of range so that appropriate action would be taken to ensure the safe storage of medicines.

There were appropriate arrangements for the safe management, use and oversight of controlled drugs. Controlled drugs (CD) were stored safely and securely with access restricted to authorised staff. Checks were undertaken and recorded by 2 staff twice a day. We reviewed documents for CD checks during our onsite inspection and found all details were correct.

Accurate, up-to-date information about people’s medicines was mostly available, particularly when being admitted to or moving between healthcare settings. We reviewed 6 medication administration records on the electronic prescribing medicine administration system. Staff documented the route and time of medication administration and antibiotics had a review date and indication recorded. Most patients had all their medications prescribed, however, we found 1 patient who had been admitted for over 24 hours and had none of her regular medications prescribed. We escalated this to the staff caring for the patient at the time of the inspection.

Allergy status of patients was routinely recorded on all medicine records seen. This meant that allergies were highlighted, and medicines could be prescribed safely. Weights of patients were recorded, which was needed to help support calculating weight-based medicines prescribing. Venous thromboembolism (VTE) assessments were mandatory and were required to be completed by the medical team. However, we found a patient had not had their reassessment at 24 hours completed despite being prescribed prophylactic medication. We escalated this to the staff caring for the patient at the time of the inspection.

Ward 23 underwent their ward accreditation medicines management standards audit in June 2025 and found they were compliant with 26 out of 27 standards giving them a 97% compliance. Their most recent safe and secure handling of medicines audit was completed between August and October 2025 and found they scored 85% compliance with legislation and regulation and best practice standards.

Staff had identified an area for improvement on Ward 23 around reducing medicinal wastage. The ward had experienced an increase in the number of medicines which had been placed in their bins which was due to be returned to pharmacy. As a result, staff were reviewing their prescribing and medication processes on the ward. This included prescribing medication on discharge, reviewing what medication patients had with them to reduce the amount of medication prescribed and obtained from the hospital pharmacy as well as identifying what medication they had at home to reduce any unnecessary prescriptions.