Source · CQC inspection
The Robert Jones & Agnes Hunt Hospital
Provider The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust
Type NHS Healthcare Organisation
Region West Midlands
Last inspected 15 Oct 2025
Overall rating: Good View full CQC report
Domain ratings
Safe
Good
Effective
Good
Caring
Good
Responsive
Good
Well-led
Good
Current CQC assessment
Good
The service is performing well and meeting our expectations.
Ratings by service
Critical care
Good
Critical care
Good
Surgery
Good
Surgery
Good
Critical care
Good
Critical care
Good
Surgery
Good
Surgery
Good
Earlier inspection findings
Must-do actions (1)
Must-do action 1 of 1
Must do
Well-led
Ensure there are effective systems to assess, monitor and review the performance of the unit so the safety and quality of care provided can be improved.
Should-do actions (34)
Should-do action 1 of 34
Should do
Well-led
Ensure there is a robust plan of action to ensure zero tolerance of bullying and harassment is strengthened.
Should-do action 2 of 34
Should do
Well-led
Ensure low training compliance rates are monitored.
Should-do action 3 of 34
Should do
Well-led
Consider the frequency to renew Disclosure and Barring Service (DBS) checks for executive and non-executive directors.
Should-do action 4 of 34
Should do
Well-led
Consider updating the Board Governance Framework to ensure it is reflective of amendments, including committee reports.
Should-do action 5 of 34
Should do
Safe
Ensure all staff consistently complete mandatory training in a timely manner.
Should-do action 6 of 34
Should do
Safe
Ensure contingencies are reviewed in the event of multiple emergencies occurring simultaneously, which require staff to travel with a patient to another hospital, to provide adequate senior cover.
Should-do action 7 of 34
Should do
Safe
Review action plans for ensuring staff have completed mandatory training modules to meet the trust target of 92%. This should include safeguarding, mental capacity and DoLS training.
Should-do action 8 of 34
Should do
Effective
Ensure that all policy and standard operating procedure documents are reviewed and updated appropriately.
Should-do action 9 of 34
Should do
Safe
Ensure mandatory training compliance levels for nursing and medical staff are improved to comply with trust targets.
Should-do action 10 of 34
Should do
Safe
Ensure all appropriate staff have received training in identification and treatment of patients with sepsis.
Should-do action 11 of 34
Should do
Safe
Ensure all areas of non-compliance with the Department of Health guidelines for critical care facilities (Health Building Note 04-02) are identified and included on the local risk register.
Should-do action 12 of 34
Should do
Safe
Ensure all relevant patients are screened for MRSA.
Should-do action 13 of 34
Should do
Safe
Ensure there are formal practices and procedures to ensure medical staffing cover on the high dependency unit is safe.
Should-do action 14 of 34
Should do
Safe
Ensure all handover and ward round arrangements were formalised and consistent.
Should-do action 15 of 34
Should do
Safe
Ensure arrangements for reviewing the high dependency unit’s performance in relation to medicines management was consistent and all staff were aware monitoring takes place.
Should-do action 16 of 34
Should do
Safe
Ensure the cover provided by the outreach team is safe and compliant with standards of art in that it is appropriate.
Should-do action 17 of 34
Should do
Effective
Ensure appropriate audits are carried out and used to improve the performance of the unit and outcomes for patients.
Should-do action 18 of 34
Should do
Effective
Ensure all relevant policies are up to date.
Should-do action 19 of 34
Should do
Effective
Ensure that compliance with Mental Capacity Act and Deprivation of Liberty training complies with trust target and evidence capacity assessments are carried out for all relevant patients.
Should-do action 20 of 34
Should do
Well-led
Ensure all relevant risk registers include all risks identified by the unit and actions reviewed at all appropriate governance meetings.
Should-do action 21 of 34
Should do
Well-led
Ensure there is assurance the leadership of the high dependency unit is effective.
Should-do action 22 of 34
Should do
Safe
Ensure robust arrangements are in place for consultant paediatrician cover both in and out of hours.
Should-do action 23 of 34
Should do
Safe
Ensure all ligature points including those in accessible staff areas are thoroughly risk assessed and mitigated.
Should-do action 24 of 34
Should do
Responsive
Consider the availability of written information being available or accessible in other languages than English.
Should-do action 25 of 34
Should do
Well-led
Ensure overbooked clinics are reported as an ‘incident’ so this can be scrutinised through the governance systems.
Should-do action 26 of 34
Should do
Responsive
Identify ways of recording and collecting the reasons for clinic cancellations so they can be analysed.
Should-do action 27 of 34
Should do
Responsive
Consider the staff interface with the main outpatient area environment, with a view to achieving a more efficient and comfortable experience for staff and patients.
Should-do action 28 of 34
Should do
Safe
Be clear about anticipated timeframes for achieving the remaining measures identified for controlling the risks associated with overcrowding in the main outpatient area.
Should-do action 29 of 34
Should do
Caring
Ensure information for patient’s in an ‘easy read’ format to support informed consent is available.
Should-do action 30 of 34
Should do
Well-led
Ensure there is a system in place to assure itself outpatient nurse leaders are able to have regular representation at divisional governance and interdepartmental senior nurse meetings.
Should-do action 31 of 34
Should do
Safe
Ensure all staff are up to date with safeguarding training.
Should-do action 32 of 34
Should do
Responsive
Consider providing electronic displays to keep patients informed of waiting times.
Should-do action 33 of 34
Should do
Safe
Consider addressing the issues of Mondays and Tuesdays being busier and the risks to patient safety.
Should-do action 34 of 34
Should do
Safe
Ensure radiation signs are up in theatre to alert people that radiation was in use for interventional procedures.