Home / Sources / CQC / The James Cook University Hospital
Source · CQC inspection

The James Cook University Hospital

Provider South Tees Hospitals NHS Foundation Trust Type NHS Healthcare Organisation Region North East Last inspected 19 Jan 2024

Location rating: Good  View location on CQC

Location ratings by domain

Five CQC key questions

Ratings held for this CQC location under the inspection framework, last inspected 19 January 2024. Ratings extracted from individual reports are shown separately below.

Safe
Good
Effective
Good
Caring
Good
Responsive
Good
Well-led
Good

Most recent report indexed for actions

The date and rating here are from an individual report, not necessarily the location's latest assessment. Report ratings are extracted with AI; verify the original PDF.

Type: Location
Date: 19 January 2024
Rating extracted from this report: Good
Actions indexed: 5 must-do 8 should-do

Read this inspection PDF

AI-extracted 3 Jun 2026

Earlier inspection findings

pre-2024 framework · 5 must-do 8 should-do

Must-do actions (5)

Legal requirements based on regulation breaches identified during inspection.

Must-do action 1 of 5
Must do
Safe
The service must ensure staff complete regular skills and drills training.
Regulation: Regulation 12 (Safe care and treatment)
⚠ However, staff told us that impromptu ‘skills and drills’ sessions did not happen very often.
Must-do action 2 of 5
Must do
Safe
The service must review the escalation or surge process to ensure that on call rota is effective and there is not an over reliance on specialist midwives which impact negatively on staffing out of hours.
Regulation: Regulation 18 (Staffing)
⚠ Leaders said most closures happened overnight when there was no specialist or senior midwives to assist with clinical workload, which was indicative of over-reliance on specialist and non-clinical staff and ineffective on-call systems or escalation processes.
Must-do action 3 of 5
Must do
Safe
The service must monitor compliance with the calculation, escalation and timely review of MEOWS and take action to improve compliance, and ensure instances of deterioration are identified and actioned promptly
Regulation: Regulation 12 (Safe care and treatment)
⚠ However, where the MEOWS score triggered a review, this was achieved within the appropriate time frame between 50% to 86% in 5 out of the 11 months (100% in the other 6 months). The action plan for these audits stated incidents had been cross checked for instances of deterioration and …
Must-do action 4 of 5
Must do
Well-led
The service must ensure all governance and risk concerns are followed up and any mitigations applied are effective and reviewed.
Regulation: Regulation 17 (Good governance)
⚠ Meeting minutes did not always record actions for follow-up, dates for completion or progress updates and this may result in slow or ineffective governance processes. This data gave rise to the concern that leadership struggled to make effective interventions to remedy repeated problems which had appeared over 3 quarters’ worth …
Must-do action 5 of 5
Must do
Safe
The service must address the environmental and equipment shortfalls that affect the safety, privacy and dignity of women, birthing people and babies
Regulation: Regulation 15 (Premises and equipment)
⚠ The design of premises and facilities was not entirely suitable. The maintenance and use of facilities, premises and equipment, did not always keep people safe. We found areas of concern needing urgent improvements. There was no birthing pool on delivery suite or on the Midwifery Led Unit (MLU). Staff used …

Should-do actions (8)

Recommended improvements to enhance service quality.

Should-do action 1 of 8
Should do
Safe
The service should ensure staff are trained in safe birthing pool evacuation.
Should-do action 2 of 8
Should do
Safe
The service should ensure all medical staff complete safeguarding training.
Should-do action 3 of 8
Should do
Safe
The service should ensure full security of delivery suite and fit for purpose birthing pools and evacuation equipment if water births are to be offered as an option.
Should-do action 4 of 8
Should do
Safe
The service should continue to improve on triage processes and monitoring through audit.
Should-do action 5 of 8
Should do
Safe
The service should continue to explore ways to improve the current staffing challenges.
Should-do action 6 of 8
Should do
Well-led
The service should consider alternative ways to communicate learning with staff in addition to email.
Should-do action 7 of 8
Should do
Well-led
The service should complete the work on the vision and strategy for maternity services.
Should-do action 8 of 8
Should do
Well-led
The service should monitor incidents by ethnicity.