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The Royal Orthopaedic Hospital

Provider The Royal Orthopaedic Hospital NHS Foundation Trust Type NHS Healthcare Organisation Region West Midlands Last inspected 21 Jan 2026

Overall rating: Good  View full CQC report

Domain ratings

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

Current CQC assessment

Single Assessment Framework

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

Good Assessed 21 January 2026
The service is performing well and meeting our expectations.
Date of assessment: 6 to 7 May 2025. The Royal Orthopaedic Hospital is a specialist orthopaedic centre and is one of the largest providers of elective orthopaedic surgery. It offers three tiers of service: routine orthopaedic operations; specialist services, such as spinal surgery; and diagnosis and treatment of malignant bone conditions. The trust specialises in planned treatments of large and small joint replacement, spinal services, orthopaedic oncology and bone infections. This assessment looked at the children and young person services as it had not been inspected since 2014, which we …

Ratings by service

Services for children & young people
Good
Dec 2024

Earlier inspection findings

pre-2024 framework · 28 should-do

Should-do actions (28)

Recommended improvements to enhance service quality.

Should-do action 1 of 28
Should do
Well-led
The trust should consider the way in which challenge is documented within minutes to be reflective of the discussions taken place.
Should-do action 2 of 28
Should do
Well-led
The trust should consider a review of the corporate risk register to include date of entry to the register, frequency of update and a review of the control measures in place.
Should-do action 3 of 28
Should do
Well-led
The trust should review the systems in place to manage staff anxieties regarding the future of the trust and potentially losing its identity as an orthopaedic specialist trust.
Should-do action 4 of 28
Should do
Safe
The trust should ensure all staff complete their safeguarding training.
Regulation: Regulation 12.2(c) (Safe care and treatment)
Should-do action 5 of 28
Should do
Well-led
The trust should ensure that staff understand its policies on locking medical records and resuscitation trolleys.
Regulation: Regulation 17.2(d) (Good governance)
Should-do action 6 of 28
Should do
Well-led
The trust should ensure staff complete patient records fully including fluid charts and malnutrition universal screening tools.
Regulation: Regulation 17.2(d) (Good governance)
Should-do action 7 of 28
Should do
Caring
The trust should ensure staff respond to patient call bells promptly.
Regulation: Regulation 10.2(b) (Dignity and respect)
Should-do action 8 of 28
Should do
Responsive
The trust should ensure wards are adapted to the needs of patients living with dementia.
Regulation: Regulation 9.1(a)(b)(c)3.(b) (Person-centred care)
Should-do action 9 of 28
Should do
Caring
The trust should ensure patients are not moved at night.
Regulation: Regulation 10.2.(a) (Dignity and respect)
Should-do action 10 of 28
Should do
Safe
The trust should remind staff to record cleaning jobs done and action taken on fridge temperature variation.
Should-do action 11 of 28
Should do
Safe
The trust should share its surgery safety thermometer performance with patients and visitors.
Should-do action 12 of 28
Should do
Caring
The trust should provide formal training on breaking bad news.
Should-do action 13 of 28
Should do
Responsive
The trust should minimise in-clinic wait time for day surgery patients.
Should-do action 14 of 28
Should do
Well-led
The trust should continue to develop solutions to overcome its fragmented information systems
Should-do action 15 of 28
Should do
Responsive
The trust should maintain the pace of its engagement work and develop an approach to consulting spinal patients
Should-do action 16 of 28
Should do
Well-led
The trust should continue to develop its management information to monitor pre-assessment recalls, surgical site infections for spinal or other complex surgery.
Should-do action 17 of 28
Should do
Safe
The service should ensure staff are up-to-date with all mandatory and safeguarding training.
Regulation: Regulation 12.2(c) (Safe care and treatment)
Should-do action 18 of 28
Should do
Safe
The service should ensure the flooring in the dirty utility can be cleaned effectively and does not present as a slip and trip hazard.
Regulation: Regulation 15(a),(c) (Premises and equipment)
Should-do action 19 of 28
Should do
Safe
The service should ensure consultant reviews are appropriately recorded to show they have been conducted within 12 hours of patient admission.
Regulation: Regulation 12.2(a)(b) (Safe care and treatment)
Should-do action 20 of 28
Should do
Safe
The service should ensure they implement local Safety Standards for Invasive Procedures (LocSSIPs) and assess the need for these against all invasive procedures carried out.
Regulation: Regulation 12.2(a)(b) (Safe care and treatment)
Should-do action 21 of 28
Should do
Well-led
The service should ensure they conduct regular simulation and emergency drills for the unit to be able to assess what went well and where improvements were needed.
Regulation: Regulation 17.2(a)(b) (Good Governance)
Should-do action 22 of 28
Should do
Well-led
The service should ensure all policies and procedures are up-to-date to accurately reflect the types of patients admitted to the unit.
Regulation: Regulation 17(1) (Good Governance)
Should-do action 23 of 28
Should do
Responsive
The service should ensure the design of the unit meets the needs of patients living with dementia.
Regulation: Regulation 9.1(a)(b)(c)3.(b) (Person-centred care)
Should-do action 24 of 28
Should do
Well-led
The service should ensure all current risks for the service are recorded on the local risk register.
Regulation: Regulation 17.2(b) (Good Governance)
Should-do action 25 of 28
Should do
Safe
The service should consider displaying the results of the safety thermometer, so they are visible to patients and visitors.
Should-do action 26 of 28
Should do
Effective
The service should consider providing access to a speech and language therapist during weekends.
Should-do action 27 of 28
Should do
Caring
The service should consider providing formal training on breaking bad news to staff
Should-do action 28 of 28
Should do
Responsive
The service should consider clearly displaying in the unit that information and leaflets are available in other languages.

Location details

CQC ID: RRJ05
Local authority: Birmingham
Region: West Midlands

Inspection report

Type: Location
Date: 20 December 2019
Rating: Good
Actions: 28 should-do
AI-extracted 3 Jun 2026

Related PFD reports

2024-0674 — Michael Thompson (Dec 2024)
None — Bryan Catanach (Dec 2015)
2015-0088 — Leonardus Vries (Mar 2015)