Bishop Auckland 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

This means we looked for evidence that the service met people’s needs.

We assessed 7 quality statements. The service understood the diverse health and care needs of people and their local communities. Patients were at the centre of their care. The service supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs. The service promoted equity in experience and outcomes for groups who might experience inequality. Staff helped patients to make plans for the future.

However, patients could not always access care when they needed it. They did not always involve people in decisions following complaints or tell them what had changed as a result.

At our last assessment we rated this key question Good. At this assessment the rating has remained Good.

Good: This meant people’s needs were met through good organisation and delivery.

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.

We scored the service as 3. The evidence showed a good standard. The service 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.

Patients and families we spoke with told us staff helped them to make their own decisions about their care and treatment, as part of the pre-operative assessment process.

Staff told us that patients that were particularly anxious or who required carers to stay with them were accommodated in side rooms. Carers were involved in care giving so that routines were disrupted as little as possible.

The service had lead staff for example, for learning disability and dementia and policies for staff to follow for care for patients with learning disabilities and mental health needs. Staff we spoke with shared examples of how they managed the needs of patients with a learning disability and how patients were actively involved in care planning.

The evidence showed some shortfalls. Although the service understood the diverse health and care needs of people and their local communities, care was not always joined up and flexible to support choice and continuity.

Clinicians we spoke with told us the electronic patient record system (EPR), installed in October 2022, did not interface with some electronic systems used by referrers such as GPs and other providers. They could not always see all essential information prior to admission. This meant patients had to repeat information on admission and if staff then assessed that the patient’s needs could not safely be met, this resulted in ‘on the day’ cancellation of operations.

We asked the trust to provide data for numbers of cancellations and reasons for cancellation of elective surgery by site and specialty, for the last 6 months. There were 23 cancellations at BAH out of 113 cancellations (20%) across the care group, for the period 1 March to 31 August 2025.

Although requested, reasons for cancellation were not provided. It was therefore unclear how many cancellations were due to insufficient pre-operative information.

However, the trust confirmed most on-the-day hospital initiated surgical cancellations (within 24 hours) were re-booked on the day of surgery, and there was an average of 19 per month that were cancelled and not immediately rebooked across the care group.

The trust tracked and monitored bed moves at night (between 8pm and 8am). There were 277 for the period 1 July to 30 September 2025; none were recorded for BAH. It also monitored numbers of non-surgical boarded patients on surgical wards. For the period 1 April to 30 September 2025, general medicine (100%) accounted for the highest numbers of non-surgical boarded patients, counted at midnight. The daily average number of medical patients boarded on surgical wards was 0.4 patients. The trust had a process to ensure clinical review of boarded patients was timely.

Staff planned for patients’ discharge, including liaison with care managers and discharge facilitators. The discharge facilitators spoke with families from admission through to discharge to ensure they were kept up to date and that complex needs could be met. Staff met in a huddle at 10am each day to discuss individual plans for patients for discharge.

However, discharges were sometimes delayed for other than clinical reasons. For example, for the period 1 April to 30 September 2025 there were 10 delayed discharges from in-patient wards at BAH. The main reasons for delays were cited by the trust, as awaiting availability of resource for assessment and start of care at home.

We scored the service as 3. The evidence showed a good standard. The service supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

The trust acknowledged the care group was not yet fully compliant with the Accessible Information Standard (AIS). However, to address this, a working group was set up to review the requirements of the standard and create a structured AIS action plan.

Some elements were in place, including functionality within EPR to record and flag communication and information needs, as well as supporting resources such as ‘Take 5’ learning materials to promote awareness of reasonable adjustments. Work was ongoing to ensure consistent use of these systems across all departments and to embed the identification, recording and meeting of individual communication needs into routine clinical and administrative processes.

The trust was progressing work to strengthen accessible information through a developing health literacy approach and expansion of materials available in accessible formats, such as easy read documents and translated information.

The trust website had accessibility tools to enable users to adjust font size, contrast and language.

Staff made information and leaflets available in most languages spoken by patients within the local demographical area and in a variety of formats.

Information governance systems included confidentiality of patient records. Computers were password protected. Staff logged out of programs when they were not using computers.

We scored the service as 2. The evidence showed some shortfalls. The service had systems for people to share feedback and ideas, or raise complaints about their care, treatment and support. However, they did not always involve people in decisions about their care or tell them what had changed as a result.

Patients and carers had opportunities to give feedback on the service they received in a manner that reflected their individual needs. For example, patients could contact the patient experience team directly by telephone or send an email to share a compliment or to provide feedback or complaints. Feedback forms were available on the trust website and there was the option to select languages other than English.

The trust also gathered feedback via the friends and family test tool, which was available on the trust website. Posters were displayed in the departments with quick response (QR) codes, which enabled feedback to be sent digitally. The trust noted a decrease in responses by the QR code which meant there were potential accessibility issues.

However, complaints were not always managed timely, in accordance with trust policy. For example, data for the period 1 July to 30 September 2025, showed the surgery care group received 123 complaints, and 83 (67%) remained open.

Of 19 complaints trust wide, referred by complainants to the Parliamentary and Health Services Ombudsman (PHSO), 7 (37%) related to the surgery care group. This meant complaints were apparently not always answered to complainants’ satisfaction by the trust, and they felt the need to escalate their complaint to the PHSO.

We asked the trust how it demonstrated learning from complaints received in the last 12 months, broken down by site. The data we received for the period 1 September 2024 to 1 October 2025 detailed learning from 9 closed complaints across all sites. None were for BAH. Most related to communication and documentation issues.

However, data for October 2025 showed that there were still 21 PSII actions overdue and 45 complaint actions overdue across the care group. This meant there were delays in embedding learning from incidents and complaints.

We asked the trust for the last 6 months Duty of Candour compliance data. As of end September 2025, there were 8 surgery incidents where duty of candour was overdue for completion. One of these was for BAH.

An external review commissioned by the trust as part of its ongoing investigation of the breast service at other trust locations, raised concerns regarding historic delays in Duty of Candour. In addition, trust board papers identified deterioration in Duty of Candour compliance as a current concern across the care group, which resulted in lack of timely learning from complaints and incidents. Trust data showed numbers of open incidents and complaints continued to increase. However, the care group had some recovery plans to support improvement with Duty of Candour which the trust was monitoring.

Managers and staff had access to the feedback from patients, carers and staff and used it to make improvements across the care group. For example, purchase of soft close bins for the wards to reduce noise during the night and introduction of a hydration station in ophthalmology for longer stay patients and improved signage across various departments. The trust informed patients of improvement actions through ‘you said, we did’ posters displayed in public areas.

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure that people could access the care, support and treatment they needed when they needed it.

The Trust continued to significantly under-perform against the NHS England Faster Diagnosis Standard and the Cancer 62 day waiting time standard. Performance against the 28-day diagnosis standard at 54.5%, was insufficient to meet the NHS England ambition. Performance was especially pressured in the breast and skin services. Performance against the 62-day treatment standard for cancer at 65.6%, was insufficient to meet the NHS England ambition.

However, NHS England data for the period October 2024 to October 2025, showed the trust performed consistently better than the national average for elective patients waiting to start consultant-led treatment, waiting within 18 weeks; 69% against the national average 62%.

Similarly, for the same period, the trust was better than the national average for patients who waited over 52 weeks to start consultant-led elective treatment; 1.3% against the national average of 2.3%.

The trust and care group were aware that general surgery and dermatology were not meeting planned activity targets. However, the trust had recovery plans in place.

We scored the service as 3. The evidence showed a good standard. 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.

The trust had a varied demographic with areas of deprivation, increasing diversity and significant rurality which influenced healthcare needs. The Index of Multiple Deprivation (IMD) data showed that approximately 60% of the trust’s catchment population lived in the top 40% of most deprived areas nationally.

Staff recognised the importance of health optimisation and prehabilitation, designed to optimise patients’ physical, nutritional, and psychological health before surgery and help reduce complications, accelerate recovery, and improve post-treatment outcomes.

Patients who required more intensive support were referred to the trust’s ‘Waiting Well’ service. This was provided through a multi-disciplinary team including Advanced Wellbeing Practitioners, and AHPs, who worked with patients to identify their health and wellbeing goals and agree a support-plan.

The care group had a named health inequalities lead, who worked with the trust public health team to agree priorities for action to promote equity in patient experiences and outcomes.

The trust had undertaken equality impact assessments of their policies and procedures to ensure they did not place vulnerable people or people with protected characteristics at a disadvantage.

Staff received equality, diversity, inclusion and human rights training. Trust target compliance was met by all job roles at all sites.

We scored the service as 3. The evidence showed a good standard. 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.

Staff accessed the trust DNACPR policy through the intranet.

Staff created personalised care plans to account for the patient’s needs, wishes and feelings, including advance decisions to refuse treatment. They worked with all relevant internal and external teams and provided patients with options for their discharge.

Care for people who were nearing the end of their life was communicated in a sensitive and dignified way. Discharge coordinators facilitated rapid discharge home in accordance with patient’s wishes, where practicable.

Staff linked with palliative care and pain management teams to ensure patients nearing end of their life were as comfortable as possible.