Hull Royal Infirmary

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

At our last inspection we rated this key question as requires improvement and remained the same at this assessment.

There were several areas within the medical care core service where systems and processes for ensuring safe care and treatment were not fully effective. These combined issues increased the risk of avoidable harm to patients and resulted from ongoing shortfalls relating to staffing, as well as new concerns regarding governance, safe care, and treatment standards.

There was low compliance with timely observations, sepsis screening and escalation, highlighting substantial gaps in basic observation practice and in the early recognition and management of deteriorating patients. Clinical audits, including NEWS, were not consistently completed, monitored or supported by effective action plans, constituting a breach of Regulation 17 (Good Governance).

Falls training compliance was low. There was no evidence that allied health professionals had been offered falls related training meaning the trust could not be assured staff had the skills required to prevent and manage falls safely. This constituted a breach of Regulation 12 (Safe Care and Treatment).

There were continued shortfalls in staffing levels, training and professional support, meaning the service could not consistently ensure sufficient numbers of suitably qualified and competent staff. This demonstrated ongoing non-compliance with Regulation 18 (Staffing).

Duty of Candour requirements were not consistently met, with delays and omissions in written apologies and feedback following incidents. While staff understood Duty of Candour principles and communicated openly with patients and families, compliance was not reliable, resulting in a breach of Regulation 20 (Duty of Candour).

Find out what we look at when we assess this area in our information about our new Single assessment framework.

Learning was not consistently supported by timely and compliant Duty of Candour processes, and statutory requirements were not always enacted, with overall compliance remaining below the expected standard. However, staff demonstrated a clear understanding of incident reporting and described examples of open communication with patients and families following incidents.

Trust wide compliance with Duty of Candour was 35% for verbal and written apologies and feedback following moderate or above harm incidents.

Although up to date data was unavailable in October 2025 due to a system change, June 2025 data demonstrated significant variation across medicine care groups.

These failures meant that patients and families were not consistently informed in a timely way, and written apologies and feedback were not always provided, resulting in a breach of Regulation 20 (Duty of Candour). In response, from October 2025 the trust introduced a requirement for mandatory completion of verbal and written apologies and feedback before Duty of Candour forms could be submitted.

Despite these shortfalls, there were strengths in the learning culture at ward level. Staff understood which incidents to report and were confident in doing so. They shared examples of incidents relating to staffing shortfalls.

Learning from incidents was shared at team meetings, on notice boards and through a range of communication channels. Staff on one ward explained how they used a recent complaint as a real life learning scenario, helping to strengthen practical skills and receiving positive feedback as a result.

The trust planned to reintroduce a weekly safety newsletter. Themes raised through incidents included falls, pressure ulcers, violence and aggression, delays in care and the use of escalation spaces.

The trust had transitioned to a new electronic system for managing incidents, complaints and PALS, intended to strengthen reporting, integration and consistency across care groups. However, system changes had contributed to gaps in oversight, particularly in relation to Duty of Candour assurance.

Staff did not consistently operate effective processes that supported safe, coordinated care and continuity across pathways and transitions and they did not always collaborate with patients, relatives, and healthcare partners to maintain safety during admissions, transfers, and discharges.

The trust had standard operating procedures to support safe and effective patient flow; however, gaps in oversight meant these were not consistently followed, affecting flow and continuity of care. We found examples of inappropriate patient placement, including patients cared for in unsuitable areas for extended periods. Patients on the short stay unit often remained beyond the 72 hour target, and some were clinically inappropriate for the ward. Most admissions occurred at night, increasing the risk of patients being placed in environments that did not support safe observation or timely assessment.

Some medically fit patients also remained in the discharge lounge for several days and, in some cases, weeks. The trust had plans in place to relocate the discharge lounge, with patient stays expected to be typically 2–3 hours, extending up to 6 hours where delays occurred (for example, while awaiting care packages or equipment).

During periods of high operational pressure, care group staff implemented a continuous flow model and applied the temporary escalation space standard operating procedure to maintain safe and timely movement of patients. Risk assessments were in place for areas used as temporary escalation spaces. However, a recent audit identified concerns on one specialist medicine ward where patients cared for in temporary escalation spaces did not always have their confidentiality, privacy and dignity maintained. Staff told us they were frustrated by this, as they felt patient experience and quality of care were being compromised by factors outside their control. This demonstrated that, although systems existed, they were not always effective in ensuring consistently safe practice during escalation.

These issues meant the service was in breach of Regulation 12 (Safe care and treatment).

The service faced significant delays linked to community capacity for home care and domiciliary care. As a result, a substantial number of inpatient beds were occupied by patients awaiting onward care, affecting patient flow, elective admissions, and the ability to accept patients from emergency and acute pathways.

There were high numbers of patients who were clinically fit for discharge with no criteria to reside (NCTR), including people aged 75 and over who were classed as stranded or super stranded. These pressures impacted patient flow but were system wide in nature and not attributable to shortcomings within the service’s internal processes.

Despite these issues, we heard examples of positive practice. Leaders told us they kept patients on frailty assessment wards if they were expected to be discharged within 72 hours to support safe and timely flow. The complex discharge team provided staff training on discharge processes, and patient discharge assistants played a coordination role that supported and enabled discharge.

Patient experience indicators reflected a reasonable performance. In the 2024 trust wide adult inpatient survey, the trust scored 7.0/10 for patients reporting they did not wait long for a hospital bed; the equivalent score for Hull Royal Infirmary was 6.2/10. Patients we spoke with described overnight transfers as smooth and well managed.

The service worked effectively with people to understand and manage safeguarding risks. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff demonstrated a good understanding of safeguarding procedures and were confident using the reporting systems to make alerts and referrals. All safeguarding related policies were clear and comprehensive.

Safeguarding link nurses based on wards disseminated information to other staff members and acted as a point of contact for advice and escalation.

Staff liaised regularly with the local authority safeguarding team, who provided timely advice and support for complex safeguarding cases. Clear information sharing pathways were in place, which helped ensure concerns were escalated appropriately and decisions were made in partnership with external agencies. Staff gave instances where concerns had been raised including some complex examples where collaborative working had been commended by the trust executive.

The training policy stated that safeguarding adults training was mandatory for all trust employees. Compliance was strongest for levels 1 and 2, with most staff meeting or exceeding the 85% target and some areas achieving 100%. Deprivation of Liberty Safeguards (DoLS) training also showed high compliance, with most staff meeting or exceeding the 85% target. However, we identified gaps in safeguarding training records, including among allied health professional staff. Leaders told us that actions were underway to improve compliance, but some gaps had not been fully highlighted through existing governance and oversight processes.

The service did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Routine audits were in place to monitor NEWS compliance and to assess whether patient observations were completed within required timeframes. Despite this, compliance with NEWS observations and sepsis screening remained low across all care groups. This meant patients at risk of sepsis were not consistently monitored, assessed, or escalated in a safe or timely manner.

A single point prevalence audit undertaken in November 2025 reviewed 11 units and wards. Only 3 of the 11 areas were compliant with NEWS requirements and sepsis screening. The audit identified overdue observations, incomplete sepsis screening, and significant variation across departments, with several areas demonstrating extremely low levels of compliance. These findings highlighted substantial gaps in basic observation practice and in the early recognition and management of deteriorating patients. This constituted a breach of Regulation 17 (Good Governance).

Despite these concerns, the Acute Medical Unit (AMU) had recently been recognised as the best performing area for escalating patients identified through the NEWS system. The unit had doubled its compliance levels for escalation, demonstrating strong clinical leadership and effective processes for recognising and responding to deterioration, and was setting the standard for further improvement projects across the organisation. In addition, for unplanned critical care admissions the service exceeded the national target of 75% for recording and responding to NEWS2, achieving 92% in Q1 and 100% in May 2025.

In addition, actions to address low compliance formed part of the Humber Health Partnership Sepsis Improvement Plan, which included a requirement for each specialty to develop their own sepsis screening and management improvement plan. The trust confirmed that a new audit process would be introduced to improve reliability and oversight. A new QI dashboard was being used to monitor use of the sepsis tool, supported by three monthly reports from the digital team, and quarterly audit results were reviewed by the trust’s patient, sepsis, and resus group to support sustained improvement. The trust also planned to introduce a bespoke in house e‑learning programme from April 2026, as funding for the external e‑learning package ended in August 2025.

The service did not ensure that diagnostic pathways for suspected sepsis were timely, reliable, or aligned with national standards. A risk recorded on the risk register identified that patients were not consistently managed in line with the National Institute for Health and Care Excellence (NICE) guideline Sepsis: recognition, diagnosis and early management (NG51), which sets out evidence based recommendations for the early recognition, assessment and management of sepsis. As a result, patients with suspected sepsis did not always receive timely or reliable diagnostic assessment.

Falls related training was not consistently completed across staff groups, and compliance often fell below the trust’s 85% target. Basic falls prevention training was limited to additional clinical services staff, with only one care group meeting the required standard. Compliance with the ‘Fallsafe’ module varied, and data for some staff groups, including medical students, allied health professionals and nursing staff, was incomplete. The more detailed ‘Carefall’ module remained well below target, with low completion among some medical staff.

Despite these concerns, we observed some examples of good practice. Patients had access to call bells which were within their reach linked to a central display. Those identified as being at risk of falls wore yellow wristbands, enabling staff to recognise them easily and provide appropriate support. Staff also used bed bumpers, mattress alarms, and red socks to reduce the risk of falls.

The trust’s falls prevention educator and practice development matron delivered face to face falls prevention training for the non‑registered workforce and provided induction training for new doctors and registered nurses, which contributed to a reduction in falls. Bespoke ward based training was also provided in response to identified needs. The lead pharmacist supported falls risk reduction by reviewing the falls medication risk assessment, identifying medication related risks and delivering targeted training. The trust also participated in the Falls AQUA collaboration, commissioned by the ICB, to support evidence based quality improvement, shared learning and benchmarking in falls prevention.

We observed regular, effective handover meetings, safety huddles, and ward and board rounds. These were attended by all relevant staff, who were able to share information and escalate concerns. Staff routinely discussed key information to maintain patient safety, including falls risk, mobility, care plans, suitability for step down or discharge, dietary needs, and infection status. These meetings evidenced collaborative decision making and ensured consistent oversight.

Most staff demonstrated good practice in identifying, monitoring, and escalating other risks. Care records showed no gaps with risk assessments. Staff used central monitoring on the hyper acute stroke unit to support patients requiring enhanced observation, allowing continuous monitoring of heart rhythm (ECG) and oxygen saturation levels.

Staff described strong support from medical staff and specialist teams such as the tissue viability nurses. The recent introduction of a tissue viability team showed that for one ward only a single pressure ulcer was reported in the previous month.

Although staff worked hard to maintain safe environments and equipment, several significant estates and environmental issues meant the environment did not consistently support the delivery of safe, dignified or well observed care.

Several older wards required refurbishment, and multiple estates issues had a direct impact on patient experience and safety. In the discharge lounge, the shower could only be used in a limited way due to leakage into the room below. The short stay ward had no shower facilities, despite patients often staying longer than 72 hours. On the AMU ward, ongoing issues with toilets being out of service meant there were insufficient facilities for a 30 bed area. The ward did not have ensuite provision, resulting in patients needing to use commodes. Ventilation was also ineffective, with ambient temperatures reaching 24.5°C. This meant a breach of Regulation 15 - Premises and Equipment.

Not all ward areas had quiet rooms available for patients or relatives. One identified quiet room was being used as a storage area and another for a boarded patient. We also observed some storerooms left open and accessible to patients and visitors, creating avoidable risks.

Although most wards had secure entrances and exits, direct observation from nurses’ stations was limited in some areas due to the building layout. On Ward 37 (the respiratory support unit), patients with higher acuity who required enhanced observations were sometimes cared for in side rooms outside the direct line of sight, increasing the risk of delayed recognition of deterioration.

Despite these concerns, staff detected and controlled many day to day risks in the care environment. Emergency equipment was accessible across wards and clinical areas, including hoists, defibrillators, suction machines and blood pressure monitors. Resuscitation trolleys were tamper evident, clean and regularly checked. Equipment to support the prevention and management of pressure ulcers, such as specialist mattresses and cushions, was available, and staff reported they could access bariatric equipment when required.

Staff completed daily safety checks of specialist equipment, including portable oxygen, suction and automated defibrillators. Equipment stocks were checked daily or weekly in line with trust guidance, and stock rotation was well managed. COSHH items were stored safely. Electrical equipment had undergone safety testing within the previous 12 months, and oxygen cylinders were maintained and stored securely.

Most wards were clean, organised and free from clutter. Sluices were clean and odour free. Sharps containers were clearly labelled, dated and stored correctly. Kitchens were clean and well maintained, and food storage was appropriately managed. Fire extinguishers were in date and routinely tested, and ward level risk checks were completed weekly and monthly. Fire safety training compliance was mostly high for clinical and non-clinical staff.

Overall, while staff maintained equipment and managed many local risks well, the wider environment required improvement to ensure it consistently supported safe, dignified and well observed care.

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

Safe and effective staffing processes were not consistently effective across the service. Although systems were in place, they did not reliably ensure safe staffing levels or appropriate oversight.

Matrons held daily responsibility for safe staffing across the care group on a rotational basis, and twice daily safe staffing meetings were held to review clinical staffing and patient acuity. Some care groups also held weekly staffing reviews with the nurse director, matron and deputy, supported by agreed minimum staffing levels and use of a safe nursing care tool to calculate staffing requirements. Despite these arrangements, the processes did not function effectively in practice. On the day of the assessment, there was high acuity on the respiratory ward and, although the ward was fully established, staffing felt under pressure. Senior leaders later confirmed they had not been made aware of this issue and that it had not been escalated, demonstrating a failure in the staffing oversight and escalation systems.

Nursing staffing remained a significant risk across several wards. Moderate to high turnover, sickness, reliance on temporary staffing and inconsistent deployment meant the hospital could not demonstrate safe or sustainable staffing arrangements. These issues undermined workforce resilience and continued to impact service stability.

Fill rate data describes how many planned staffing hours were delivered, with 100% indicating full cover. Most shifts were covered with registered nurses, although there were gaps in some community, frailty and therapy wards, as well as one medical specialty ward.

Unregistered staff on the Same Day Emergency Care (SDEC) ward had a significantly low fill rate of 35%, indicating substantial shortfalls against planned staffing. For other staff groups, including allied health professionals, additional clinical services, administrative staff and students, the data showed variation in sickness, capacity and fill rates. Although sickness and turnover were generally low, this variation contributed to inconsistent staffing cover across services.

Staff told us that staffing anomalies created significant and sustained pressure. They reported being moved across wards to cover shortages, which they found demoralising, and said nurses and healthcare assistants (HCA’s) were frequently redeployed even when their own ward was safely staffed. Staff felt this negatively affected job satisfaction and left them working at full stretch. Some patients reported lower staffing levels at night times and described staff as being “rushed”.

Staff told us that staffing levels did not always take boarded patients into account, resulting in insufficient staff to manage the additional workload. When wards were considered above establishment, staff were sometimes reassigned to areas outside their usual skill set, which they felt compromised safe and effective care.

Although rotas were usually completed in advance, staffing levels did not consistently reflect patient acuity. Staff caring for highly dependent patients reported that this placed further pressure on them and contributed to an already fragile workforce environment.

These issues meant the trust continued to be in breach of Regulation 18 (Staffing).

Following our assessment, we were informed that recommendations from the safer nurse staffing establishment review were scheduled for consideration by the Trust Board in December 2025. Although recruitment activity was strong and processes were efficient, senior leaders had identified areas requiring further investment, particularly the need for additional healthcare support workers. This had been prioritised within the trust’s staffing plans.

Training

Mandatory training modules were standard across all care groups; however, role specific and locally mandated training requirements varied between services. Across most care groups, mandatory and role specific training largely met or exceeded the trust’s 85% target, supporting safe and effective staffing. However, there were pockets of poorer compliance. None of the care groups met the trust’s target for nationally mandated resuscitation training, indicating a wider area for improvement in ensuring staff maintained essential clinical competencies.

Compliance for some staff groups, such as allied health professionals and students, was unclear due to incomplete data or training gaps, meaning the trust could not demonstrate that all relevant staff had received the required training.

Compliance with locally mandated training was also variable, and across most care groups did not meet the trust’s 85% target.

The Oliver McGowan (Learning Disability and Autism) training data was limited because the trust had implemented a phased roll out from November 2025, meaning full compliance information was not yet available.

Overall, these gaps meant the trust could not provide assurance that all staff had completed the training necessary to carry out their roles safely. This meant the trust continued to be in breach of Regulation 18 (Staffing).

Despite these issues, we heard examples of positive practice. The GMC results showed that resident doctors reported generally positive experiences of support and supervision. Clinical and educational supervision scores remained strong, with cardiology and oncology achieving particularly high results, including confidence in supervision during both in hours and out of hours working.

Staff described a range of professional development opportunities across roles, including apprenticeships, preceptorship programmes for newly qualified staff, and access to postgraduate study.

The service effectively assessed, managed, and controlled infection risks.

The environment and areas we visited were visibly clean, and systems and processes to promote hygiene were in place. Notice boards at the entrance to each ward displayed a cleaning summary outlining tasks, frequency and responsible staff. Domestic staff were employed by an external contractor, with each ward allocated a dedicated domestic worker who followed a checklist specifying where, how and when to clean. Managers from the contracting company regularly checked standards and audited performance. Several areas achieved five star cleanliness ratings.

Staff cleaned equipment after use, labelled it appropriately and stored it correctly. Cleaning records were up to date and showed that ward areas were cleaned regularly. Clinical and non‑clinical waste was managed appropriately. Staff followed infection prevention principles and complied with the trust’s uniform policy.

Hand washing facilities and sanitising gel were available throughout all ward areas we visited, with clear signage promoting effective hand hygiene. Personal protective equipment (PPE), including aprons and gloves, was readily available and stored in trolleys outside side rooms for ease of access. We observed staff using PPE appropriately and following bare arms below the elbows guidance, correct handwashing technique and appropriate use of hand gel.

The hospital’s 2024 adult inpatient survey scored 8.8/10 for ward cleanliness. Patients described the environment as “spotlessly clean” and told us staff washed their hands regularly.

Audit results for IPC, hand hygiene and the environment showed moderate compliance across ward areas. The audits highlighted key successes and identified areas for improvement, with recommendations and actions to support learning.

The service monitored Healthcare Associated Infection (HCAI) surveillance indicators, and the IPC team provided regular support, audits and oversight. During infection incidents, staff ensured effective isolation and management, making appropriate use of single rooms to maintain safety while supporting patient flow. Senior leaders met with multidisciplinary teams following any reported infection to complete post infection reviews, identify actions and share learning.

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities, and preferences.

National Institute for Health and Care Excellence (NICE) recommends that inpatients in an acute healthcare setting have their medicines reconciled within 24 hours of admission. Medicines reconciliation (comparing the list of medicines people were taking prior to admission with what was currently prescribed) was conducted using various sources to ensure the information was correct and up to date to reduce the risk of a medicines error occurring. Trust medicines reconciliation rates were low with only 66% of patients having this completed during their hospital stay and only 26% of patients within the first 24 hours (on average over a 6 month period). This meant the trust was in breach of Regulation 12 Safe Care and Treatment, and it must improve medicines reconciliation rates to prioritise medicines safety.

The opening of some medicines can shorten the expiry date. We saw a case where the opening date had not been documented and therefore it was not known if the medicine was usable. Another medicine we found was not in its original container and had also expired. These had not been identified by staff and posed a risk of expired medicines being used. Safe and secure audits did not include expiry date checking of medicines.

The 2024 survey showed bottom five performance nationally, scoring 3.3/10 for patients being given information about medicines to take home on discharge, indicating that people were not always supported to understand their medicines. Some patients we spoke on the discharge lounge confirmed this.

Nursing staff told us that pharmacy professionals were not always visible on wards but could be contacted if needed and evidence that medicines reconciliation had been completed was not always accessible.

When antimicrobials were prescribed to treat an infection, the indication was not always recorded on the prescribing system and there was not always evidence of a timely review of the medicine as per the trust guidelines. The trust was aware this required improvement.

Patients were not always given their medicines at the right time. This included time critical medicines such as those for the treatment of Parkinson’s Disease. The NICE quality statement QS164 states ‘Adults with Parkinson's disease who are in hospital or a care home take levodopa within 30 minutes of their individually prescribed administration time.’ We saw medicines being given outside the 30 minute time frame on several occasions. There was a risk that people’s Parkinson’s symptoms would not be adequately controlled. We also found that one person did not get their medicine for treatment of Parkinson’s Disease as the hospital did not stock it at the time of the inspection. However, there was no evidence that an alternative medicine was being sought in a timely manner so there was a risk that their Parkinson’s symptoms would worsen.

Despite this, medicines were stored safely, securely and were well organised. Controlled drugs were stored securely with restricted access; record keeping was accurate and a process was in place to report any discrepancies found.

A system was in place to replenish medicines when needed and a regular service was provided by the pharmacy to supply medicines and manage stock. Staff were able to contact designated pharmacists and pharmacy technicians for support. Where patients required medicines to take home, these were provided by the pharmacy or prescribed as a primary care prescription.

We saw evidence that patients suspected of being at risk of sepsis were monitored regularly and interventions were made promptly. For one patient identified as having a high risk of sepsis, this was recognised promptly, and treatment was initiated within 1 hour of identification.

For the patients records reviewed, time critical medicines were given at appropriate times in most cases and a system was in place to prompt staff if medicines were due or overdue. Details of patient allergies were documented well in all patient records reviewed and red alert bands were worn by patients with allergies to alert staff of this.

Where appropriate, patients were able to self-administer medicines, however, for one patient who was self-administering, a risk assessment had not been completed to ensure this was safe to do. Where antibiotics had been prescribed, an indication or a duration of treatment were not always documented. The hospital was aware this required some improvement.

The hospital’s 2024 adult inpatient survey scored 8.1/10 for patients being able to take their own medication when required.