Darlington Memorial Hospital

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

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 at another trust location 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.

One of the actions which applied across all sites, was documented on the risk register as ‘personnel trained in Advanced Life Support (ALS)’. 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 for DMH and BAH combined (staff that worked across both sites) identified no medical and no nursing staff that were required to complete the training. Data for staff who worked solely at DMH, showed only 10 medical and 29 nursing staff were identified as requiring the training for the surgery care group at this site. Compliance was 90% for the 10 medical staff and 97% for the 29 nursing staff.

Another of the safety actions identified following this incident was training in the use of emergency portable, mechanical cardiopulmonary resuscitation (CPR) equipment for all sites. Training records for DMH and BAH combined (staff that worked across both sites) showed 42 of 127 staff listed, completed the training. However, it was unclear whether this list represented all relevant staff that were required to complete the training. There was no data for staff who worked solely at DMH. 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 trainingin 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 were able to describe recent incidents that they had reported. For example, pressure area damage and falls. Staff told us they received feedback following investigations. 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 61% to 96%. 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 30 September 2025, the percentage of days of the month that staff were signed into the tool ranged from 43% to 95% 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.

Records and patient data were kept securely. Electronic patient records were accessed via individual staff log in and staff were seen logging out after viewing records on mobile computers. Wards had lockable trolleys to store paper records, and some were kept at the patient’s bedside.

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, swab count boards were not completed in accordance with Association for Perioperative Practice (AfPP) guidelines and trust policy. For example, we observed, the boards had no patient name or unique identifier recorded, or both.

The policy for counting items 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.

There was no emergency surgery undertaken at Bishop Auckland Hospital (BAH) as there was no high dependency facility. This meant deteriorating patients from BAH who required higher levels of care were transferred to DMH and this was facilitated by the acute intervention team.

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. However, we did not see any occupied TES beds during our assessment.

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, DMH and BAH combined (staff that worked across both sites), medical staff compliance against the trust target of 85% for safeguarding vulnerable adults level 2 was 77%. Safeguarding children level 2 compliance was 72%, safeguarding children level 3 was 80% and safeguarding children level 3 specialist competencies compliance was 25%. However, nursing staff compliance for DMH and BAH combined (staff that worked across both sites) and DMH alone, 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.

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, although not all staff we spoke with knew who the named safeguarding leads were.

We found 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. Those we looked at, were complete.

We also saw some paper venous thromboembolism (VTE) risk assessments at the end of some patient’s beds. Completion of these was inconsistent across all wards. For example, an emergency surgical patient with known dementia, did not have their VTE risk or mental capacity assessments completed with them on admission. We returned later that same day to check and the assessments were still incomplete.

We reviewed records for another emergency surgical patient who had previous VTE prior to admission and had been prescribed and administered a medicine which helps prevent blood clots. Their medicine needed to be stopped prior to surgery, however no VTE risk assessment was completed, although they were noted to be at significant risk. In addition, the patient was not provided with antiembolism stockings and there was no documentation to show that these had been considered or discussed with the patient. In addition, another patient fell during admission and sustained a fractured femur. Their VTE risk assessment was not completed.

Audit data for the care group showed VTE documentation and risk assessment compliance for March to August 2025, 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 DMH 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 medical staff did not meet the 90% trust target at any site; DMH and BAH (staff that worked across both sites) combined compliance, was 55%, and 83% for those who worked solely at DMH. Combined compliance by administrative and clerical staff (staff that worked across both sites) was 77%. Howevercompliance by administrative staff who worked at DMH only, was 91%, against the trust target of 90%.

Compliance by nursing staff and allied health professionals at DMH and BAH combined (staff that worked across both sites) and those who worked solely at DMH, met the trust target. This meant 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.

Emergency equipment checks by clinical staff were audited and showed theatre recovery was consistently below trust target. They achieved only 77% compliance in August 2025 and the trust did not have an action plan improve compliance. However, emergency resuscitation equipment checks on the wards were completed daily.

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 were emergency call bells situated inside and outside each anaesthetic room. There was sufficient storage for equipment. Recovery did not have a designated paediatric friendly area, and staff we spoke with told us there was no access to the dirty utility room, following reconfiguration to accommodate a high dependency unit. This meant staff had to take bodily fluids for disposal through clean areas, as they could not use the facilities the high dependency unit now occupied. Staff were unclear whether this was risk assessed.

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.

On the wards, restricted access areas such as storerooms where items subject to the control of substances hazardous to health (COSHH) regulations were stored, were not always kept locked and items stored safely and appropriately in accordance with trust policy. For example, we found tubs of disinfectants in an unlocked cupboard in a food preparation area on ward 11, and the dirty utility room on ward 32 was not secure. This meant there was a risk that hazardous products could be accessed by vulnerable patients and visitors. We brought this to the attention of staff at the time and they were secured.

Staff ensured stock items were stored in line with manufacturer's guidance and all items we checked were within their expiry date.

There was an environment 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.

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, there was 1 RN fewer than planned on the day and night shifts and another ward had 1 RN fewer than planned on the day shift. Managers we spoke with told us they were working hard to upskill newly qualified nurses to improve the skill mix and staff retention. 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 in theatres and wards across all sites and we saw that suboptimal staffing impacted on patient safety. One ward reported more staffing-related incidents than other wards in the care group. Managers explained this ward had increased its number of beds from 16 to 29, approximately 2 years ago, although the established workforce was unchanged. As a result, the ward relied heavily on bank and agency staff to fill staffing gaps, particularly during periods of unplanned sickness absence. Managers explained that due to financial constraints, and because the increased bed capacity was not considered permanent, approval to increase the substantive workforce was not granted. 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. Trust wide across the surgical care group, there was a 12% vacancy rate for non-consultant career grade medical staff (7.84 WTE posts).Training grade positions were over- establishment across the trust by 15%.

Absence rates for medical staff across the care group was low, but DMH and BAH orthopaedics absence ranged from 5% to 10% between June and August 2025. Dermatology absence ranged from 1% to 12% for the same period and there were 4.43 (8%) consultant posts vacant at DMH.

The trust regularly used bank and locum medical staff across the surgery care group to fill vacant shifts. For example, for the period 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. At DMH, 12% anaesthetics shifts were filled by locums.

DMH had no foundation year 1 (FY1) doctor cover on ward 14, so overnight patients were accommodated on ward 11. There were 1 registrar and 1 consultant on call every day. However, staff told us these staff were often busy in theatre or on the wards, which resulted in delays. At the weekends there was only 1 registrar, which staff told us could be particularly challenging.

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 green for DMH. Hower, 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 appropriate mandatory training, in accordance with policy. The trust target was 85%, however, deteriorating patient and resuscitation training data for medical staff showed compliance was 50%, and clinical services staff compliance was 67%. Major haemorrhage simulation training hosted at DMH and conducted in September 2025, 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 56% and combined figures for DMH and BAH (staff that work across both sites) compliance was 27%. 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 and 3 doctors we spoke with told us they did not know when a VTE risk assessment should be reassessed.

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. 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 provided by the trust, showed the trust 90% compliance target was met for all staff groups.

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 DMH.

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 DMH. 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 sharps waste disposal was in accordance with national guidance and trust policy.

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. They had access to personal protective equipment (PPE). However, on 1 ward, there were no trolleys to store PPE outside 3 rooms that were occupied by patients with infections.

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 safe 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 found that medicines reconciliation was not always completed in a timely way. The trust audit showed an average of 15% medicines reconciliation in 24 hours and was lowest in those wards that did not have pharmacy cover (trust target 60%).

We saw 1 record that showed a patient had missed doses of 1 of their regular medicines for 2 weeks, the reason for this was not recorded. Allergies had not been correctly captured in a timely way for a second patient, increasing the risk of harm. We also saw 2 examples where antimicrobial prescribing was not in line with trust guidance. However, trust audit showed increasing compliance with choice of antimicrobial to above trust target in 2 wards (September 2025).

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 could access pain relief when needed. The hospital was piloting a quality improvement project offering patients paracetamol tablets to manage pain whilst avoiding the need to have intravenous (IV) paracetamol. Other work was looking at how to optimise pain management for patients with a hip fracture. The trust also planned to provide copies of Royal College of Surgeons approved pain leaflets (available in different languages) for patients in the surgical elective admission lounge. On discharge, letters were sent electronically to people’s GPs so that records could be kept up to date.

We saw occasional gaps in the fridge temperature monitoring records on 1 ward. Medicine fridge temperatures were checked daily on the other 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.

There was a programme of regular medicines audits to help ensure policy was followed in practice. Prescription stationery was securely managed, but staff were unclear about how to dispose of spoilt forms, and this was not clearly described in policy. The trust’s safe storage audit found occasional issues and in 1 ward area the audit form had not been completed for June to August 2025.

The trust was actively embedding strengthened governance processes for the oversight of non-medical prescribing. 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.