Source · CQC inspection

UHBW Bristol Campus

Provider University Hospitals Bristol and Weston NHS Foundation Trust Type NHS Healthcare Organisation Region South West Last inspected 1 Aug 2025

Overall rating: Requires Improvement  View full CQC report

Domain ratings

Five CQC key questions
Safe
Requires Improvement
Effective
Good
Caring
Outstanding
Responsive
Good
Well-led
Outstanding

Current CQC assessment

Single Assessment Framework

From 2024 CQC rates services through ongoing assessments rather than comprehensive inspections.

Requires Improvement Assessed 1 August 2025
The service is not performing as well as it should and we have told the service how it must improve.
Date of assessment 4 June to 10 June 2025. We conducted an off-site assessment of specific parts of urgent and emergency care services at the adult emergency department of UHBW Bristol Campus (also known as Bristol Royal Infirmary). This assessment was to follow up on actions the service had taken after we identified breaches of 2 legal regulations at our last assessment in June 2024. These were regarding not enough medical staff to meet demand at weekends and not enough trained fire wardens in the department. We found the service had …

Ratings by service

Urgent and emergency services
Requires Improvement
Jun 2025
Urgent and emergency services
Requires Improvement
May 2024

Regulatory breaches & enforcement

Current-framework "must do" equivalent

Breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, stated verbatim in the CQC assessment.

Breaches identified (2)

Breach Overall
This assessment was to follow up on actions the service had taken after we identified breaches of 2 legal regulations at our last assessment in June 2024.
· 1 Aug 2025
Breach Safe
We found 2 breaches of legal regulations in relation to safe care and treatment and safe staffing.
Regulation: Regulation 12 (Safe care and treatment) · 13 Sep 2024

Earlier inspection findings

pre-2024 framework · 4 must-do 8 should-do

Must-do actions (4)

Legal requirements based on regulation breaches identified during inspection.

Must-do action 1 of 4
Must do
Safe
The service must ensure staff complete daily checks of emergency equipment.
Regulation: Regulation 12 (1)(2)(a)(d)
⚠ Staff did not always carry out daily safety checks of specialist equipment. Records showed neonatal resuscitaires on central delivery suite were not always checked daily in November 2023. We found on the midwifery led unit staff did not always check emergency ‘grab boxes’ to respond to conditions such as pre-eclampsia, …
Must-do action 2 of 4
Must do
Safe
The service must ensure medical staff have completed an appropriate level of safeguarding training to carry out their duties.
Regulation: Regulation 18 (2)(a)
⚠ Not all medical staff had completed safeguarding training updates. Safeguarding training compliance for medical staff obstetric consultants needed to improve. As of 15 December 2023, 84% of obstetric consultants and 9% of obstetrics and gynaecology junior doctors had completed safeguarding children level 3 training updates. The service had recognised compliance …
Must-do action 3 of 4
Must do
Safe
The service must ensure that 'red flag' midwifery staffing incidents are monitored effectively, including delays to induction of labour, in line with national guidance.
Regulation: Regulation 18 (1)
⚠ The service did not effectively monitor maternity ‘red flag’ staffing incidents in line with National Institute for Health and Care Excellence (NICE) guideline 4 ‘Safe midwifery staffing for maternity settings. Midwifery staffing incidents were reported on the perinatal quality surveillance matrix but there was a lack of oversight of the …
Must-do action 4 of 4
Must do
Well-led
The service must ensure incidents are reviewed in a timely manner.
Regulation: Regulation 17 (2)(b)
⚠ Incidents were not always reviewed in a timely way. We reviewed three maternity rapid incident review meeting records and found that there was 11, 31 and 54 working days between the incidents and the review meetings. This was not in line with the trust standard operating procedure for the patient …

Should-do actions (8)

Recommended improvements to enhance service quality.

Should-do action 1 of 8
Should do
Safe
The service should ensure that 'red flag' midwifery staffing incidents are monitored in line with national guidance.
Should-do action 2 of 8
Should do
Safe
The service should ensure that hand hygiene audits are completed every month.
Should-do action 3 of 8
Should do
Responsive
The service should ensure timeliness of doctor review in maternity triage.
Should-do action 4 of 8
Should do
Responsive
The service should ensure there is a dedicated maternity triage phoneline.
Should-do action 5 of 8
Should do
Effective
The service should complete record audits to ensure the quality of record keeping in maternity services.
Should-do action 6 of 8
Should do
Safe
The service should ensure staff are aware of the location of ligature cutters.
Should-do action 7 of 8
Should do
Safe
The service should ensure there are enough midwifery staff to provide a full range of maternity choices including use of the midwifery-led unit.
Should-do action 8 of 8
Should do
Safe
The service should ensure emergency grab boxes are checked and ready for use.

Location details

CQC ID: RA7C1
Local authority: Bristol, City of
Region: South West

Inspection report

Type: Location
Date: 1 March 2024
Rating: Good
Actions: 4 must-do 8 should-do
AI-extracted 3 Jun 2026