University Hospital North Durham

Ratings - Surgery

• Overall

  Requires improvement

• Safe

  Inadequate

• Effective

  Requires improvement

• Caring

  Good

• Responsive

  Requires improvement

• Well-led

  Requires improvement

Our view of the service

The surgery service operates at 3 main sites, with elective and emergency surgery being undertaken at Darlington Memorial Hospital (DMH) and University Hospital of North Durham (UHND), and elective (general surgery, orthopaedics, chronic pain, ophthalmology, dental, endoscopy, ear nose and throat, head and neck, and dermatology) undertaken at Bishop Auckland Hospital (BAH).

This assessment looked at surgery services due to aged rating and was prompted in part by notification of an incident following which a person using the service died. This incident is subject to further investigation by CQC as to whether any regulatory action should be taken. As a result, this inspection did not examine the circumstances of the incident.

However, the information shared with CQC about the incident indicated potential concerns about the safety of surgery. This inspection examined those risks.

We conducted this unannounced assessment on 7 to 9 October 2025. We assessed 33 quality statements across the safe, effective, responsive and well-led key questions.

We visited clinical areas and spoke with patients, their families and carers. We looked at health care records and a range of policies, procedures and other documents relating to the running of the service.

We spoke with 110 staff, including senior leaders, managers, clinical staff and non-clinical workers across the care group.

We rated the surgery service as requires improvement.

The rating of surgery has been combined with the ratings of the other services from the last inspections. See our previous reports to get a full picture of all the other services at UHND.

In our assessment of surgery services at University Hospital North Durham, Darlington Memorial Hospital and Bishop Auckland Hospital, we identified significant and serious patient safety concerns. These related to safe staffing, escalation where patients were deteriorating, record keeping and learning from incidents.

We took enforcement action and served a Warning Notice under Section 29A of the Health and Social Care Act 2008, which requires the trust to make significant improvement to the quality of healthcare provided.

Requires Improvement

We rated the service as requires Improvement. We found breaches of the regulations in relation to safe care and treatment, safe staffing and governance.

• The service did not have a positive safety culture, and lessons were not always learnt to continually identify and embed good practice.
• Staff did not always assess, manage and monitor risks to people's health and safety or mitigate them where identified.
• Staff did not always keep comprehensive patient records.
• The service did not make sure there were enough suitably qualified, skilled, competent and experienced clinical staff to meet the needs of patients and keep them safe from harm.
• Staff did not always follow current evidence-based good practice and standards.
• The service did not always routinely monitor people’s care and treatment to continuously improve it.
• The service did not always tell people about their rights around consent.
• The service did not always make sure that people could access the care, support and treatment they needed when they needed it.
• Governance systems and audits were not effective in identifying or addressing areas for improvement.
• Staff did not always feel their concerns were listened to.

However:

• The service worked well across teams and services to support people and help them to lead healthier lives.
• Staff treated people as individuals, with kindness, empathy and compassion.
• The service promoted the wellbeing of their staff.

In instances where CQC has begun a process of regulatory action, we may publish this information on our website after any representations and/or appeals have been concluded, if the action has been taken forward.

If we have requested an action plan, this will be requested upon publication of the final report.

People's experience of this service

Feedback from patients, their families and carers we spoke with onsite was positive about the care being provided.

Patients told us that they were happy with the care they had received and were informed of what to expect during their stay in hospital.

They told us they were offered pain relief and were happy with the food and drink options that were available.

Patients told us that staff were helpful, accommodating and polite. They said staff introduced themselves prior to giving care.

However, some families told us that they did not always feel fully informed and involved in decisions regarding care and treatment of their relatives.