University Hospital North Durham

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

This means we looked for evidence that people were protected from abuse and avoidable harm.

We assessed 8 quality statements. The service did not have a positive safety culture, where lessons were learnt to continually identify and embed good practice. Systems and pathways were not safe or embedded. The service did not always work well with patients to understand and manage risks or detect and control potential risks in the care environment. The service did not ensure there were enough qualified, skilled and experienced staff and that all staff completed mandatory training. They did not always make sure that medicines were managed safely.

However, staff knew how to recognise and report abuse.

At our last inspection we rated this key question good. At this assessment the rating has changed to Inadequate.

Inadequate: This meant people were not safe and were at risk of avoidable harm.

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.

We scored the service as 1. The evidence showed significant shortfalls. The service did not have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate reported safety events in a timely manner. Lessons were not learnt to continually identify and embed good practice.

Although initial reporting of incidents onto the electronic reporting system was mostly timely, subsequent completion of comprehensive patient safety incident investigations (PSII), and associated action plans were not. This meant there was delayed identification of mitigation to reduce future risk, and delayed implementation of actions and lessons learned.

For example, we asked managers about learning from a serious patient safety event that happened in theatre in December 2024. Some of these actions applied across the care group, which meant at all sites where surgery was conducted. They told us only 2 of 11 identified safety actions they were aware of, were achieved. However, the final PSII report, ratified in November 2025, 11 months after the incident, and after our assessment visit, identified 22 safety actions with due dates completed, and 7 still outstanding.

This meant the action plan and its progression was not communicated effectively, as managers and staff were not fully aware of all the safety actions and when they were due to be completed. Suitable and sufficient controls were still not in place and embedded, to mitigate further potential patient safety risks.

Furthermore, the action plan alluded to monthly audit activities to monitor effectiveness of completed safety actions. We asked for the care group audit schedule and tracker to confirm this at local level. However, we found the trust had not completed any audits against the actions shown in the action plan. This meant it was unclear how the trust was assured there was sufficient oversight of how effective safety controls were and whether they were embedded into practice. Managers explained the lack of oversight across theatres was due to senior leadership vacancies and staff sickness.

The trust identified that theatres at UHND were not all compliant with NHS England guidance for operating theatre facilities (NHS Estates HBN 26 facilities), due to lack of emergency call bells. We found that except for 1 recently refurbished theatre, there were still no emergency alarms in 9 of 10 theatres. We brought this to the attention of the trust at the time and following our assessment, the trust confirmed that work to install the emergency alarm system would commence early November with completion by mid December 2025.

Further mitigation of the risk associated with this incident was documented on the risk register as ‘personnel trained in Advanced Life Support (ALS)’. This action was applicable across the surgery care group, which meant it applied to all sites where surgery was conducted. After our inspection, the trust clarified there was 24-hour cover for every shift by an Emergency Response Team which included ALS trained personnel. This team included a surgical registrar, the acute intervention team and additional staff from other departments such as ITU and general medicine. This team attended all emergency calls (trust-wide) and provided ALS -led care. Although trust training data showed all the acute intervention team were up to date or booked to attend ALS training, the aggregate mandatory training data provided showed for UHND, only 1 member of medical staff and 21 nursing staff were identified as requiring ALS for the surgery care group at this site. Compliance was 100% for the 1 medical staff and 100% for the 21 nursing staff.

One of the safety actions identified following this incident was training in the use of emergency portable, mechanical cardiopulmonary resuscitation (CPR) equipment across the care group, which meant at all sites where surgery was conducted. Training records received showed a list of 54 staff who had attended the training at UHND in September 2025. However, it was unclear whether this list of attendees represented all relevant staff that were required to complete the training. In addition, the training was delivered 9 months following the incident. This meant it was unclear how the trust was assured all appropriate staff were trained in use of this specialist equipment in a timely way, after the incident.

We asked the trust for the data on their simulation training for sudden patient resuscitation in line with the Resuscitation Council UK quality standards. The trust confirmed simulations were not a formal part of the theatre training programme, but that it was planning to develop these and roll them out across all theatres at all sites. It was unclear how the trust was assured that recent training in the use of specialist resuscitation equipment, and compliance with new or updated policies and procedures resulted in effective improvements in safety or that lessons were learned to continually identify and embed good practices across the trust.

We also found examples where immediate learning opportunities were missed, and safety improvements were delayed because they were only identified as the result of patient complaints.

For example, one such complaint raised in September 2024, was acknowledged as a surgical patient safety incident by the trust 8 months later, in May 2025. This required the trust to initiate a PSII to fully understand the patient journey and identify all learning. However, the PSII was still in progress at the time of our assessment, which meant there were missed opportunities to identify immediate early learning and make appropriate changes to improve safety across the trust.

Following our assessment, trust data showed there were 483 open patient safety incidents across the care group, 43 incidents that had remained open over 60 days related to ongoing investigations in the audiology service and 108 to the breast service review (151 in total). The trust clarified they needed to remain open until reviews reliant on external support were fully concluded. The trust confirmed it was considering a business case for a small PSII investigation team to improve timeliness of investigations.

The trust had a policy for Engaging and Involving Patients, Families and Staff following a Patient Safety Incident (Including Duty of Candour). Staff we spoke with knew what was meant by Duty of Candour, and we saw examples of letters sent to patients and their families when things had gone wrong. The letters offered a written apology and explained next steps in terms of investigation timescales and contacts for engagement. However, incidents which met the Duty of Candour threshold were not always identified in a timely manner. For example, those related to historic and ongoing incidents in the breast surgery service. This meant it was unclear how the trust was assured Duty of Candour was always fulfilled as soon as reasonably practicable.

Staff we spoke with on the wards told us about recent incidents they had reported. For example, 3 related to patient discharge and gaps in recording in patient records. Laminated posters were created to ensure staff follow clear discharge protocols. An acute interventions team met every 4-6 weeks to review and learn from recent incidents.

Managers we spoke with told us they audited this to ensure all site incidents were shared. However, staff we spoke with at all sites told us they were not aware of any serious patient safety incidents, outcomes or lessons learned outside their own areas or at the other trust sites. This meant mechanisms used to share learning and implement safety actions were not effective.

We scored the service as 1. The evidence showed significant shortfalls. The service did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. Records were inconsistent and not sufficiently comprehensive to make sure there was continuity of care.

Record keeping systems and processes were inconsistent. Most records were held on the electronic patient record (EPR) system, which was installed in October 2022. These included clinical risk assessments which were captured on handheld devices and uploaded to the EPR. However, staff we spoke with showed us on the live system, examples of why they felt the EPR lacked interoperability, and demonstrated difficulties accessing all the information they needed, in one place.

Records including venous thromboembolism (VTE) risk assessments, (used to assess, for example, patients’ risk of deep vein thrombosis (DVT)), some prescription charts, and consent forms on in-patient wards were on paper. However, we saw different versions and formats of documents in use. For example, there were 2 versions of a day surgery discharge criteria checklist: 1 on EPR and a paper version. The electronic template was not as comprehensive as the paper document.

This meant it was not possible to view patient records all in one place, and there was a risk staff could not always access all the information they needed easily. There was potential risk of delayed access to clinical results, and important information could be missed or duplicated.

Staff showed us the electronic equipment they used to record clinical observations and demonstrated that the handheld devices and the central overview screens, did not synchronise or update effectively. This meant screens did not correctly show when patients’ clinical observations were completed or still required. There was a risk that staff and managers did not have immediate, accurate overview of current patient records when recording of clinical observations was delayed or missed. Staff told us they had reported these issues to the digital support team previously and were unaware of when this might be resolved. After our inspection, the trust clarified that the issues had been reported to the system provider for resolution. In addition, the manual refresh issue identified was noted centrally within the trust EPR Hazard Log.

There was a trust policy which described the process for early detection and escalation of deteriorating patients, and the handheld devices alerted nursing and medical staff when urgent patient review was required. Managers we spoke with told us they used real time reports from the electronic records systems to monitor timeliness of observations compliance with complete observation sets, in accordance with policy. However, audit data showed between 1 March and 31 August 2025, compliance with the timeliness of observation sets varied from 50% to 97%. The trust had no action plan to address the risks and improve compliance.

In addition, to receive alerts, the resident doctor and nurse in charge needed to be logged into the electronic tool. However, audit data showed between 1 April and September 2025, the percentage of days of the month that staff were signed into the tool ranged from 38% to 100% and demonstrated systemic non-compliance across all sites. It was unclear how the trust was assured that all appropriate staff used the electronic escalation tool, that escalation tracking was robust and that the risk to patients that were deteriorating or who may have sepsis and required immediate medical, or nursing review was mitigated.

We asked staff how they contacted medical staff verbally, as required in the trust’s escalation policy. They told us that some nursing and medical staff, including agency and locums, used their own mobile telephones to access a platform messaging group, which was not monitored by the trust and was not in the policy. There was no oversight of this, and it was unsafe because not all agency and locum medical staff would have the required phone numbers to be able to escalate issues promptly for medical review.

Deteriorating patients were not always identified promptly, escalated appropriately and there was limited oversight. It was unclear how the trust was assured that current systems, pathways and transitions were always safe.

Most records and patient data were kept securely. Electronic patient records were accessed via individual staff log in and we saw staff logged out after viewing records on mobile computers. Wards had lockable trolleys to store paper records, and limited essential information was kept at the patient’s bedside. However, we found unsecured patient discharge letters and take-home medicines logs containing personal and sensitive data kept on counter tops in locked clean utility rooms on the wards. Staff we asked about this told us these documents were kept like this for several months as the letters were used for audit purposes. However, they were unsure what happened to the documents once audited, and acknowledged this practice was not in accordance with General Data Protection Regulation (GDPR) principles and trust record keeping policies. When we returned to the wards the following day, some had been locked away but others were still accessible.

Medical staff we spoke with across all sites told us access to imaging and obtaining timely reports, particularly out of hours, was problematic as the service was often contracted outside of the trust.

We were concerned that in theatres the swab count boards were not completed in accordance with Association for Perioperative Practice (AfPP) guidelines and trust policy. For example, at UHND in 6 theatres we checked that were in use, the boards had no patient name or unique identifier recorded, or both.

The policy for counting items in theatre was last reviewed in 2017 and was past its next review date. However, the trust clarified it was currently under review as part of wider work to review all theatre policies and procedures.

All staff we spoke with at all sites knew who their key point of contact (general manager) for the day was and how to contact them. They escalated bed pressures and staffing challenges with the bed managers who were visible and provided support.

We observed an organisational site meeting, attended by the patient flow team, discharge liaison, care group key points of contact and infection prevention and control staff. These meetings were held twice daily at 10:30 and 15:30 and aimed to optimise bed occupancy according to clinical need and to ensure there were no mixed-sex breaches.

Meetings followed a standardised agenda and used real-time data from several sources to ensure coordination between bed demand and availability, elective lists, and emergency pressures. They also discussed the bed status for Bishop Auckland Hospital and community hospitals, to plan transfers if required. In parallel with the bed planning meeting, a daily trauma meeting took place each morning, led by the on-call consultant orthopaedic surgeon and attended by the trauma coordinator, theatre coordinator, anaesthetist, and ward team leads.

When there were insufficient beds, managers used a point in time (PIT) risk assessment tool to identify patients suitable for occupation of temporary escalation space beds, (TES beds), or those suitable to be accommodated out of specialty. The risk assessment was rated into green, amber and red (RAG) rated answers. Red answers indicated that the patient was not suitable to be cared for in a TES bed or outside of the surgical wards. Locations of non-surgical patients and those in TES beds were monitored and tracked to reduce the risk of delayed medical review. Staff we spoke with explained the fields on the incident reporting system had recently been amended to enable capture of incidents that occurred for patients in TES beds.

Staff shared information about patients shift to shift at handover meetings, recorded information on their own handwritten handover sheets and accessed patient records on portable computers, which they used at the bedside.

Safety alerts were emailed as appropriate to senior departmental leads who shared them with staff at daily safety huddles.

We scored the service as 2. The evidence showed some shortfalls. They did not always ensure staff were trained appropriately. However, the service worked well with people and healthcare partners to understand what being safe meant to them and how to achieve that.

The trust did not always ensure all staff were trained in safeguarding appropriate to their role, in accordance with the Intercollegiate document (2019). For example, medical staff compliance with safeguarding children level 3 specialist competencies was 33% against the trust target of 85%. Medical staff met the trust target for levels 1 and 2 adults and children training. Nursing staff compliance for levels 1 and 2 adults and children training met the trust target.

PREVENT (anti-racialisation) training compliance by nursing and administrative staff met the trust 90% target. However, compliance by medical staff did not meet the trust target.

We found that mental capacity assessments were recorded inconsistently, and some were completed after consent was obtained, for some patients with cognitive impairment. This was unsafe because the trust was unable to demonstrate the risk of invalid consent to care and treatment was suitably and sufficiently mitigated, for patients who lacked capacity and needed to be safeguarded.

The trust safeguarding policies were in date, linked to local authority safeguarding boards and described local arrangements and mandatory training requirements. Staff we spoke with knew how to identify adults and children at risk of, or suffering, significant harm. They knew how to make referrals correctly and were able to do so. However, not all staff we spoke with knew who the named safeguarding leads were.

We scored the service as 2. The evidence showed some shortfalls. 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.

Clinical risk assessments such as falls, pain scores and national early warning scores observations (NEWS2) were captured on handheld devices and uploaded to the EPR. However, patients were not always involved in care plans and staff did not always discuss and update clinical risk assessments with them. For example, we found venous thromboembolism (VTE) risk assessments were not always completed in patient records we looked at. In addition, audit data for 1 March to 31 August 2025 showed VTE documentation and risk assessment compliance ranged from 82% to 88% across all sites. This meant the trust could not assure itself that risks relating to people were always assessed and managed appropriately, with the involvement of the person, so they understood any decisions about this.

The trust had recently introduced a tool and pathway named ‘call for concern’, to implement Martha’s Rule. (Martha’s Rule is a UK patient safety initiative giving hospital patients, families, and carers the right to an urgent clinical review if they were worried about a patient's worsening condition, ensuring concerns were heard and acted upon quickly). Staff ask patients each day if they are concerned and this is recorded on handheld devices at the bedside every day. The tool was piloted on a ward at Darlington Memorial Hospital and rolled out trust-wide in all adult in-patient areas, in August 2025. The trust reported on the effectiveness of the system through formal reports, 4 times a year, which included numbers of calls for concern received and example case studies.

The trust displayed ‘call for concern’ posters in all wards at all sites. The call for concern provided a single point of contact for staff, patients and visitors alike, to raise concern about any aspect of patient care that arose. These were picked up by the acute intervention team. They reported an increased volume of calls following implementation of Martha’s Rule.

Staff upheld patients’ rights, provided and followed the principle of least restriction and promotion of quality of life. The trust’s rapid tranquilisation policy referenced best practice guidance in the use of physical restraint, in accordance with training standards from the Restraint Reduction Network 2021. Annual audits were required to monitor compliance. However, although we requested them for each site, the trust did not provide any data, and it was unclear how the trust was assured patients subject to restraint were kept safe.

Staff ensured that patients could access advocacy and provided information to all patients and families on advocacy and available local services.

We scored the service as 1. The evidence showed significant shortfalls. The service did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

The trust did not ensure all staff completed mandatory fire training, and did not conduct fire drills, although the fire safety policy required full staff participation in both training and fire evacuation drills.

Training compliance by nursing staff and allied health professionals met the 90% trust target, however, compliance by administrative, clerical, and medical staff was not met at any site; UHND compliance for medical staff was 80%, meaning the trust could not assure itself that all staff knew what to do in the event of a fire or how to evacuate patient and staff areas.

The trust did not ensure stock items including nutritional supplements were stored in line with manufacturer's guidance. We found expired products on 2 wards, gaps in fridge temperature monitoring records and no actions recorded when fridges had exceeded required temperature range. We found blood collection tubes which had passed their expiry date, empty point of care testing equipment boxes and out of date blood glucose meter test fluids for 2 machines. This meant patients might be given products unsuitable for consumption, blood test results might not be reliable, and staff might not be able to access the correct equipment and supplies promptly in an emergency. We brought this to the attention of staff at the time, and the expired items were removed and replaced.

Emergency equipment checks by clinical staff were audited and showed day surgery was the only area that was consistently below the Trust's target of 98% compliance across the 3 months (July to September 2025). Emergency resuscitation equipment checks on the ward appeared to be completed daily. However, we found a diary used to record the checks on 1 ward was not labelled with ward identification, meaning there would be no traceability when the diary was archived.

The day surgery clinical environment was fit for purpose, in terms of layout and accommodation. All main theatres were maintained in good order and there was a CEPOD theatre (Confidential Enquiries into Perioperative Deaths) for urgent and emergency surgeries, ensuring timely care for critical cases, which was staffed 24 hours a day. There was sufficient storage for equipment. Recovery had designated paediatric friendly areas.

Staff we spoke with in theatre told us they often experienced difficulties obtaining sterile equipment such as surgical instruments. They reported poor service from the external provider and issues regarding equipment turnaround times, which ranged from 12 to 72 hours. Staff we spoke with told us sterile supplies were not delivered at weekends, although we saw there was a transport schedule in place, which covered weekends and bank holidays.

The impact was that lists were sometimes cancelled. We asked the trust for data regarding reasons for cancellation of planned surgery lists for all sites; however, none was provided.

There was a schedule of planned preventive maintenance and essential servicing across the care group, which was up to date. All portable electrical equipment we checked was tested, serviced and labelled when next due.

There was an environmental ligature risk assessment policy. Surgery wards were not considered high risk areas. However, ligature risk assessments were completed as part of their annual risk assessment process as well as individual ligature risk assessments as needed.

On all wards we visited, restricted access areas such as storerooms where items subject to the control of substances hazardous to health (COSHH) regulations were kept, were locked and items were stored safely and appropriately in accordance with trust policy.

Quality Statement Score: 1

We scored the service as 1. The evidence showed significant shortfalls. The service did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

Overall nurse staffing establishment was not appropriately reviewed, and it was unclear how the trust had considered Royal College of Surgeons guidance, when calculating required medical staffing levels.

The trust could not assure itself all substantive and bank staff, were trained appropriately in mandatory and role specific training.

The trust used a nationally recognised workforce planning tool (safer nursing care tool) to support the safe staffing review processes for registered nurses (RNs) and health care support workers (HCSWs). There was a safe staffing policy for ward-based settings, which described how ward nurse staffing establishments were set. According to the policy, assessment and re-setting of the nursing establishment and skill mix for in-patient wards must be reported to the trust board twice a year, in accordance with NHS England National Quality Board (NQB) guidance and NHS Improvement resources. However, the trust confirmed they had not completed any formal nurse staffing establishment review or submitted a formal report to board, within the last 12 months. The reason given was staffing shortages.

There was a vacancy rate of 13.05% across the surgery care group. The most notable gap was within band 5 RN staff, where 22.60 whole time equivalent (WTE) posts remained unfilled. This was followed by band 3 non-registered staff, where 21.93 WTE remained unfilled.

On wards we visited, planned and actual nurse staffing numbers mostly matched. However, on 1 ward the afternoon shift only had 1 RN where 2 were planned. Cover was provided by a nurse co-ordinator from an adjoining ward. Day theatre rarely used bank staff and staff covered shortfalls as required. Staff we spoke with told us suboptimal staffing and patient flow issues sometimes impacted on care giving and they were unable to take adequate rest breaks, particularly at night.

The trust used high levels of bank and agency staff across all sites, particularly in main theatres at UHND. This placed additional pressure on the existing team and contributed to ongoing staffing challenges.

This meant the trust could not assure itself there were always enough appropriately skilled and competent nursing and theatre staff in post to keep people safe.

Following our assessment, the trust told us they would complete and submit the theatres workforce analysis informed business case based on Association for Perioperative Practice (AFPP) requirements, the aim being to reduce reliance on temporary workers.

We found potentially unsafe medical staffing cover at night. For example, doctors we spoke with told us there was only 1 foundation year 1 (FY1) doctor covering at night for all of trauma, orthopaedics and surgery. In addition, their duties involved attending crash calls and medical emergency calls. Although there was a surgical registrar on site at night, there was no trauma and orthopaedic registrar on site at night. This meant the FY1 doctor covering at night had no protected rest breaks. Medical staff we spoke with told us 4 registrars were leaving and vacancies were unfilled, although managers were looking to see how best they could provide support.

Trust wide across the surgical care group, there was a 12% vacancy rate for non-consultant career grade medical staff (7.84 WTE posts). Four of these posts were at UHND, giving a vacancy rate of 21%. Training grade positions were over- establishment across the trust by 15%.

Absence rates for medical staff across the care group was low, but dermatology had a 12% absence rate in June, 8% in July dropping to 1% in August.

The trust regularly used bank and locum medical staff across the surgery care group to fill vacant shifts. For example, from 1 July to 30 September 2025, trust wide, 15% of plastic surgery shifts were covered by locum medical staff, while 7% of dermatology rosters were unfilled across the trust.

Medical staffing was managed within the care groups, based on individual specialties and their specific needs. However, it was unclear how the trust had considered Royal College of Surgeons medical staffing guidance, as there was insufficient overnight cover for all surgery, trauma and orthopaedic patients.

Following our assessment, the trust clarified that the General Medical Council (GMC) feedback for resident doctors in general surgery, orthopaedics and ear nose and throat was rated red at UHND for general surgery and orthopaedics. The trust told us it would undertake a review of the orthopaedic and general surgical overnight resident doctor rota.

The trust did not ensure all staff were up to date with mandatory training, in accordance with policy. The trust target was 85%, however, deteriorating patient and resuscitation training compliance for medical staff was 50%, senior medical staff compliance was 69%, and nursing staff ILS compliance was 81%. Major haemorrhage simulation training conducted in September 2025 and hosted at Darlington Memorial Hospital (DMH), showed 42 of 119 (35%) staff attended. It was unclear from the record which sites these staff were from.

Medical staff compliance for learning disability and autism training was 63%. Allied healthcare professionals and nursing staff compliance met the 85% target at all sites. However, no data was provided for medical staff compliance with dementia training at any site, although mandated for all staff on the training matrix.

It was unclear how the trust was assured all relevant staff were fully trained to recognise and respond to the needs of deteriorating patients and vulnerable adults.

We asked the trust to provide training compliance figures for management of central lines, for all nursing staff, broken down by site. The trust provided a training slide pack, but no compliance data. Managers we spoke with told us staff received ward-based competency training, which included venepuncture, cannulation and management of central lines. However, the trust was unable to demonstrate all relevant staff were suitably and sufficiently trained.

Mandatory VTE training was not shown in the trust’s mandatory training matrix, although mandated in trust policy, with a requirement for medical and nursing staff to meet the minimum 75% pass grade. The trust provided no VTE training compliance data for any staff. We asked the trust to provide VTE audits and associated action plans for the last 12-month period, for all sites. We received 6 audits in total for the whole care group. However, 2 were repeat audits and 1 was on-going. Data for 2 audits completed at UHND showed poor compliance with VTE prophylaxis prescription. One audit looked at compliance with National Institute for Health and Care Excellence (NICE) guidance around VTE prophylaxis, which was lacking in most areas assessed.

VTE risk assessment data provided was not site specific. Figures for 1 March to 31 August 2025, showed compliance ranged from 82% to 88% across the care group. Audit findings were incomplete and although some recommendations were made following poor compliance scores, no evidence of implementation of actions was provided. It was unclear how the trust was assured all relevant staff were trained for the assessment of VTE and prophylaxis and always worked in accordance with trust policy and national best practice guidance.

The trust did not provide risk management training and could not demonstrate leaders and staff had received any training in risk management so that they knew how to ensure risks to patients were minimised and controlled.

The trust had a staff recruitment and induction policy, and we saw a comprehensive template for the trust medical education team to use for all new resident doctors in training. There was an induction template for nursing and temporary staff, and it was expected all bank and agency workers who were not substantively employed by the trust received a local induction, to be familiar with local processes, policies and procedures applicable to specific wards or departments.

The trust confirmed they did not have a bank of nursing staff who worked bank shifts exclusively. Substantive staff who worked additional bank shifts were required to be fully compliant with mandatory training prior to picking up any bank shifts. However, as some training mandated in policy was not included on the training matrix, it was unclear from the compliance data provided whether all substantive staff who also worked bank shifts were compliant with all their mandatory training.

Appraisal compliance data for all staff groups, showed allied healthcare professionals (AHPs), medical and nursing staff had met the trust 90% target. However, administrative staff compliance was 71%.

Medical, AHP and nursing staff were offered clinical supervision and professional support. Uptake was monitored by care group managers, who had oversight.

We scored the service as 2. The evidence showed some shortfalls. The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

We requested infection prevention and control (IPC) surveillance data for the last 6 months, by site and by speciality. However, we identified that the data provided by the trust was incomplete and the trust provided no infection surveillance data for UHND. The trust told us they had 1 IPC surveillance nurse and due to increased instances of surgical site infection rates at another site, the focus of the last 6 months had been there rather than at UHND. This meant it was unclear how the trust was assured there was effective surveillance to monitor infection.

Trust data for the care group, (across all sites where surgery was undertaken) for the period 1 July 2024 to 31 July 2025, showed there were more Clostridium difficile (C-difficile) infections which patients acquired within hospital than cases for patients whose infection started within the community, for most of the reporting period. C-difficile is a bacteria present in the bowel of approximately 3% to 15% of the population and can be triggered by the use of antibiotics. Nationally, most C-difficile cases were community-associated infections.

Care group quality and governance minutes for August 2025, included trust-wide IPC summary information, which was not hospital site specific. This showed since April 2025, there were 37 C-difficile cases reported and 12 (32%) were attributed to surgery. The report highlighted delays in stool sampling, laboratory submission, and some compliance gaps such as hand hygiene, PPE and commode cleaning. However, minutes for trust wide clinical governance meetings (''department of surgery'') for May and July 2025, which were attended by medical staff (consultants), did not include any IPC reports and did not demonstrate that IPC was routinely discussed at these meetings.

Medical staff we spoke with at all sites told us there was a lack of microbiologists and access to support to help manage infections, was very limited. Microbiologists are experts who identify pathogens, guide treatment, and implement, monitor, and refine infection control strategies in hospitals as part of a multidisciplinary team. Doctors we spoke with told us they raised concerns with senior leaders but were not aware of any plans to recruit more microbiologists.

Management of safe sharps waste disposal varied. For example, on 1 ward, we found an open medicinal sharps disposal bin with exposed sharps, which posed a potential risk of injury to staff. We made managers aware at the time, and the bin was removed. On 2 wards, 3 of 5 sharps waste bins we checked were not labelled correctly, which was not in accordance with national Health Technical Memorandum (HTM) guidance and trust policy. We brought this to the attention of managers at the time, and a reminder was emailed to all ward staff.

All ward environmental areas we visited were visibly clean, had appropriate furnishings and were well-maintained. Pedal operated waste bins contained the correct colour coded liners. Housekeepers kept up to date cleaning records which demonstrated that the ward areas were cleaned regularly.

We observed staff adhered to infection control principles, including handwashing. However, clinical wash hand basins in clean utility rooms did not have lever taps so were not compliant with infection prevention and control national HTM guidance.

Staff accessed up-to-date infection prevention and control (IPC) policies and procedures through the trust intranet. They were supported by IPC nurses, who provided guidance and participated in local audit activities. Audits included hand hygiene, use of personal protective equipment (PPE), equipment and environment, invasive devices and management of diarrhoeal infections.

The wards and theatres completed and documented healthcare associated infection audits mostly every month, although we saw some gaps in audit returns. The IPC team audited wards to validate the data collected. They also conducted ‘secret shopper’ audits when needed. Compliance was mostly good. Any actions were shared in daily safety huddles and follow up audits were completed to check compliance.

Wards also completed a weekly cleaning list for all medical equipment for a deep clean. Equipment was cleaned in between patient use and green stickers were used in accordance with policy, to denote cleaned equipment. Non-compliance was picked up as part of daily checks and discussed at daily safety huddles. Theatre equipment appeared clean; however, staff did not use the green sticker system, so it was unclear how staff knew stored equipment was clean and ready for use.

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure that medicines and treatments were managed safely and met people’s needs, capacities and preferences. They did not always involve people in planning.

Medicines management policies were accessed by staff through the trust intranet. Pharmacist advice and input into anaesthetic and perioperative assessment was available on request. However, pharmacy capacity meant that not all wards received regular clinical or technical pharmacy support.

We did not see any examples where critical medicines had been missed however, trust audit showed an average of 8% medicines reconciliation in a 24-hour period, lowest in those wards that did not have pharmacy cover (trust target 60%).

Staff we spoke with told us that although wards 14 and 16 were acute surgical wards, ward 17 was largely used to accommodate extra trauma patients, with the only elective patient in bay 3. The trust had completed an audit of the orthopaedic pre-assessment pharmacy work. A service improvement proposal for pharmacy services within elective surgery was developed in 2024, however, there was currently no dedicated support for wards 15 and 17 at UHND. It was unclear how the pharmacy cover was kept under review in alignment with changes in patient groups.

However, the trust pharmacy held a morning huddle to identify patients on ‘high risk’ medicines and prioritised them for medicines checks.

The trust worked with other pharmacy providers to agree quality measures, to enable benchmarking and help drive improvement.

Patients we spoke with told us they received enough information about managing their medicines before they came in for planned surgery and about any new medicines on discharge.

Patients we spoke with told us they felt informed about their medicines. For example, patients in hospital for planned surgery knew if they had to stop taking any of their regular medicines before their operation and when to restart taking them. One patient explained, ‘the clinic letter was very clear, and I brought in my own medicines. The doctor has explained what will happen on discharge. I will have painkillers and 2 laxatives, 1 only for if the other doesn’t work.’

Most people told us that their pain was well managed, although one person waited for the regular medicine rounds for pain relief ‘as it’s a busy ward’. We saw that peoples’ allergies were captured and recorded, along with weights so doses of medicines could be safely adjusted where needed, to match their needs.

We found two examples where antimicrobial prescribing did not match with the trust formulary. However, the trust completed regular antimicrobial stewardship (AMS), (the responsible, planned use of antibiotics to ensure they stay effective) audits. These demonstrated increased compliance with choice of antimicrobials, improving to above trust target in August 2025. Additionally, the trust delivered targeted AMS training to new doctors and pharmacists to support the appropriate use of antimicrobials. Action to drive improvement in antimicrobials was overseen by the trust IPC Committee.

Pre-labelled packs of ‘take home’ medicines were available to support the timely supply of medicines on discharge. However, the trust did not provide patients with post operative pain management leaflets for future reference. Discharge letters were sent electronically to patients’ GPs so that records could be kept up to date.

Although all ward clean utility rooms were keypad locked, we found stock medicines and medicines for patients to take home, stored on counter tops and not locked away.

On 2 wards, we found oral and injectable medicines stored out of original packaging, mixed batches of medicines, and mixed medicines stored together. This was not in accordance with safe practice and medicine management guidance and increased the risk of medicine administration errors. We made managers aware at the time, and they told us the medicines would be removed and replaced. However, when we returned the following day to check, on 1 ward, we still found medicines not stored in original packaging.

Medicine fridge temperatures were checked daily on the wards and theatres. However, staff did not monitor ambient room temperatures in areas where medicines such as intravenous fluids were stored. Higher ambient temperatures can increase the risk of medicines being stored outside the manufacturer’s recommended ranges, which meant there was a potential risk their quality and efficacy could be affected. We told managers at the time, and the trust told us they would review the trust medicines policy, and utilise national guidance, to develop a risk-based approach supported by a clear definition of subsequent actions.

Medicines trolleys we checked on 2 wards were dirty and we brought this to the attention of staff at the time. Managers we spoke with explained the trolleys were not on the ward equipment cleaning schedules and would ensure they were cleaned. When we returned to check the following day, we saw a revised cleaning schedule and trolleys on 1 ward were clean. However, a medicine trolley we checked on a second ward was still dirty.

On 2 wards, we found opened liquid medicines stored in the controlled drugs (CD) cabinets and medicine trolleys were not labelled with the dates of opening and expiry. We discussed this with managers at the time, and they ensured all opened and unlabelled medicines were removed and replaced. Some staff we spoke with told us it was trust policy to use purple labels to record opening and expiry dates when liquid medicines were first used. However, not all staff we spoke with were aware of this system, although they knew liquid medicine containers should be dated when opened. This meant there was a risk patients could be administered medicines that were out of date.

Controlled drug (CD) keys were held securely by the nurse in charge on the wards and CD stock levels were checked monthly by pharmacists, who also audited compliance with CD register documentation. Ward staff completed weekly balance checks. Records were mostly kept in accordance with trust policy. However, CD wastage was not consistently recorded correctly. We made managers aware at the time, and they told us they would remind staff at the safety huddles.

Patient’s own CDs were recorded correctly in a separate register.

We saw that prescription forms were securely stored, but staff were unclear about how to dispose of spoilt forms, and this was not clearly described in policy. A log was kept on the ward to record usage. However, on 1 ward, we found gaps in the records in September and December 2024, with no prescriber name, no patient name and no unique NHS number recorded. This meant the trust was unable to account for 2 prescriptions that had been used. It was unclear from the log whether pharmacy staff were aware. We made managers aware at the time, and the trust confirmed they would initiate a trust wide communication of requirements and responsibilities regarding management of prescriptions.

There was a system to enable staff to check and provide over labelled medicines to take home when pharmacy was closed. The registers we saw were completed correctly. Pharmacy audited compliance.

Medicine prescription charts we looked at were complete, although we found incomplete associated VTE risk assessments.

There was a programme of regular medicines audits to help ensure policy was followed in practice. Medicines including controlled drugs were handled safely, although the trust’s monthly safe storage audit identified some repeated issues in 2 ward areas (June to August 2025). Key themes, trends and learning from any medicines related issues identified through audit and incident reporting were shared at care group governance meetings and cascaded to wards.

The trust was actively embedding strengthened governance processes for the oversight of non-medical prescribing. One prescriber told us they received good support from the trust non-medical prescribing lead, peer reviews and regular updates through an independent prescribers’ newsletter.