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Castle Hill Hospital

Provider Hull University Teaching Hospitals NHS Trust Type NHS Healthcare Organisation Region Yorkshire & Humberside Last inspected 11 May 2026

Overall rating: Requires Improvement  View full CQC report

Domain ratings

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

Current CQC assessment

Single Assessment Framework

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

Requires Improvement Assessed 11 May 2026
The service is not performing as well as it should and we have told the service how it must improve.
Castle Hill Hospital is run by Hull University Teaching Hospitals NHS Trust as part of NHS Humber Health Partnership. It has the regional Queen's Centre for Oncology and Haematology and provides cardiac surgery, elective surgery, and day surgery facilities in the Daisy Building. The trust has approximately 1,160 inpatient beds across the two main hospitals and employs over 7,000 whole time equivalent staff to deliver its services.Our overall location rating for Castle Hill Hospital remains as requires improvement.

Ratings by service

Medical care (Including older people's care)
Requires Improvement
Aug 2025

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 Well-led
We found continued breaches of legal Regulations in relation to staffing.
Regulation: Regulation 18 (Staffing) · 11 May 2026
Breach Safe
We found new breaches of legal Regulations in relation to good governance, safe care and treatment, receiving and acting on complaints and Duty of Candour.
Regulation: Regulation 12 (Safe care and treatment) · 11 May 2026

Earlier inspection findings

pre-2024 framework · 32 must-do 12 should-do

Must-do actions (32)

Legal requirements based on regulation breaches identified during inspection.

Must-do action 1 of 32
Must do
Safe
The service must ensure it ensures that assessment of the risks to the health and safety of service users of receiving the care or treatment are undertaken within agreed guidelines and target.
Regulation: Regulation 12(1)(a)
⚠ An audit showed a 60% pass rate for sepsis management and treatment, and VTE risk assessment compliance was 82.3%, below the 95% target.
Must-do action 2 of 32
Must do
Safe
The service must ensure where responsibility for the care and treatment of service users is shared with, transferred to other persons, or working with such other persons, service users and other appropriate persons that timely care planning takes place to ensure the health, safety and welfare of the service users.
Regulation: Regulation 12(2)(i)
⚠ Significant numbers of patients were unable to leave the hospital due to waiting for onward care packages, leading to longer stays and some patients returning to acute medical wards.
Must-do action 3 of 32
Must do
Responsive
The service must ensure that an effective and timely system for identifying, receiving, recording, handling and responding to complaints is clear to those raising concerns or making a complaint.
Regulation: Regulation 16(2)
⚠ The average turnaround time for complaints was 76 days, exceeding the trust target of 40 days, and the distinction between PALS and formal complaints was unclear.
Must-do action 4 of 32
Must do
Well-led
The service must ensure it establishes and operates systems that enable the development and use of up to date, effective and relevant policies and procedural documents.
Regulation: Regulation 17(1)
⚠ The 'Medicine health group governance briefing report' (October 2022) showed 66% of procedural documents were overdue for review.
Must-do action 5 of 32
Must do
Safe
The service must ensure sufficient numbers of suitably qualified, competent, skilled and experienced nursing staff are deployed to meet regulatory requirements.
Regulation: Regulation 18(1)
⚠ The service did not always have enough nursing and support staff to keep patients safe, with actual staffing consistently below planned establishment and a whole-time equivalent shortfall of 12.8 hours.
Must-do action 6 of 32
Must do
Safe
The service must ensure sufficient numbers of suitably qualified, competent, skilled and experienced medical staff are deployed to meet regulatory requirements, particularly in evenings and weekends.
Regulation: Regulation 18(1)
⚠ The service did not have enough medical staff to keep patients safe, with insufficient consultant cover in evenings and weekends, and a whole-time equivalent shortfall of 42.96 hours.
Must-do action 7 of 32
Must do
Effective
The service must ensure staff receive appropriate support, training and professional development as is necessary to enable them to carry out the duties they are employed to perform.
Regulation: Regulation 18(2)(a)
⚠ Mandatory training compliance rates for nursing (84.7%) and medical staff (70.9%) were below the trust's 90% target for Mental Capacity Act and Deprivation of Liberty Safeguards training. Nurse appraisal completion was 72.1%, not meeting the trust target.
Must-do action 8 of 32
Must do
Safe
The service must ensure the designated safeguarding lead has completed the appropriate level of safeguarding training in line with intercollegiate guidance.
Regulation: Regulation 11
⚠ The designated safeguarding lead for the health group had not completed the appropriate level of safeguarding training.
Must-do action 9 of 32
Must do
Safe
The service must ensure that staff adhere to infection prevention and control guidance and the environment is suitable to promote safe care.
Regulation: Regulation 12
⚠ Floors in urology were littered with rubbish and had a noticeable smell of urine. Cleaning schedules were not always completed, and IPC audit compliance was as low as 76%. Staff did not always follow infection control principles, including PPE use and bare below the elbow policy.
Must-do action 10 of 32
Must do
Safe
The service must ensure systems are in place to ensure equipment is serviced and COSHH chemicals are appropriately and securely stored.
Regulation: Regulation 12
⚠ Medical gas signs were absent on storeroom doors, and Entonox and oxygen were stored inappropriately on the floor with unlocked doors, making medical gases accessible to anyone.
Must-do action 11 of 32
Must do
Safe
The service must have robust procedures in place for the identification, review and management of risk.
Regulation: Regulation 12
⚠ Electronic recording systems were not fully utilised (e.g., theatres), leading to paper-based transfers where observations and assessments were missed, and information transfer was time-consuming and prone to inaccuracy. A lack of auditing suggested unmanaged risk.
Must-do action 12 of 32
Must do
Safe
The service must ensure that there are sufficient staff with the right qualifications, skills and training to keep people safe from harm.
Regulation: Regulation 12
⚠ The service did not have enough nursing and support staff to keep patients safe, with actual staffing consistently below planned establishment. Scenarios were reported where only one registered nurse managed 27 patients, leading to staff feeling unsafe.
Must-do action 13 of 32
Must do
Safe
The service must ensure robust oversight and management of incidents and ensure incidents are shared across the health group.
Regulation: Regulation 12
⚠ Four surgery-related never events were reported, but managers did not always investigate incidents thoroughly, with insufficient pace in sharing learning and delays in investigation completion and action implementation.
Must-do action 14 of 32
Must do
Safe
The service must ensure all staff are engaged with and participate in all steps of the World Health Organisation (WHO) surgical safety checklist, the checklist is fully completed, and observational and record audits are undertaken to monitor compliance.
Regulation: Regulation 12(1)(2)(a)(b)
⚠ Surgical safety checklists required only one signature at the end of the procedure, without evidencing completion of all steps. Audits showed incomplete checklists with no pre-operative checks carried out.
Must-do action 15 of 32
Must do
Safe
The service must ensure that mandatory training compliance, including training, meets the trust target.
Regulation: Regulation 12(1)(2)(c)
⚠ Mandatory training compliance rates for nursing staff (88%) and medical staff (72%) were below the trust's 90% target.
Must-do action 16 of 32
Must do
Safe
The service must ensure all staff are aware of and consistently follow the trust's policy to safely prescribe, administer, record and store and dispose of medicines.
Regulation: Regulation 12(1)(2)(g)
⚠ Theatre staff did not always follow safe practice for controlled drug administration records (missing signatures). A medicine fridge on ward 14 was consistently at 1 degree Celsius, outside the safe range, and patients experienced delayed medication due to out-of-stock items.
Must-do action 17 of 32
Must do
Effective
The service must ensure that staff complete mental capacity and best interest decisions, when obtaining consent and they must clearly document the assessment and decision making-making process.
Regulation: Regulation 13
⚠ Mental capacity assessments were not always undertaken for patients with dementia or confusion. Patients were not always consented appropriately, with instances of incorrect consent forms used without prior formal capacity assessment, and the four-stage pillar process for assessing capacity was not followed.
Must-do action 18 of 32
Must do
Responsive
The service must ensure that all complaints are managed in accordance with service policy.
Regulation: Regulation 16
⚠ The trust had approximately 160 open complaints, with 96 being over the trust standard of 40 working days to response, with Surgery being one of the groups with the longest response times.
Must-do action 19 of 32
Must do
Effective
The service must ensure clinical care and treatment are delivered in accordance with national guidance and best practice.
Regulation: Regulation 17
⚠ Staff did not always follow up-to-date policies; 36% of trust policies were out of date or overdue for review, and 17% of surgical health group specific policies were out of date. Policies related to Mental Capacity Act, Deprivation of Liberty, Consent, and Physical restraint were not current, ratified, or clear.
Must-do action 20 of 32
Must do
Well-led
The service must ensure robust governance processes are in place to lead, manage, risk assess and sustain effective services.
Regulation: Regulation 17
⚠ Governance committee meeting minutes lacked sufficient detail for effective professional discussion, with no recorded discussion on serious incidents or never events, and no action plans to address audit delays or drive improvement.
Must-do action 21 of 32
Must do
Caring
The service must ensure staff treat patients with privacy and dignity and take account of individual needs.
Regulation: Regulation 17
⚠ In day surgery, mixed-sex care was provided in recovery bays, and we were not assured that privacy and dignity were maintained.
Must-do action 22 of 32
Must do
Safe
The service must ensure learning from never events is shared with all staff.
Regulation: Regulation 17
⚠ Insufficient pace in sharing learning from never events was observed, and some ward staff could not provide recent examples of shared learning or list top incident-related risks beyond broad categories.
Must-do action 23 of 32
Must do
Safe
The service must improve its monitoring and auditing of surgical safety checklists and ensure the finding of these audits are shared with staff.
Regulation: Regulation 17
⚠ The last completed audit of surgical safety checklists (August 2022) was incomplete with no pre-operative checks carried out.
Must-do action 24 of 32
Must do
Well-led
The service must ensure staff have access to up to date evidence-based policies and procedures.
Regulation: Regulation 17(1)
⚠ 36% of trust policies were out of date or overdue for review, and 17% of surgical health group specific policies were out of date, indicating staff may not have access to up-to-date guidance.
Must-do action 25 of 32
Must do
Effective
The service must improve the monitoring of the effectiveness of care and treatment, timeliness of investigations, reviews and audits and implementation of change.
Regulation: Regulation 17(1)
⚠ The health group's internal data was not assured to be used for national benchmarking. Audit data for pain and preoperative fasting was not provided, and some national audit submissions were delayed or not participated in.
Must-do action 26 of 32
Must do
Safe
The service must ensure that serious incidents are reported and investigated in a timely manner in line with national guidance.
Regulation: Regulation 17(1)
⚠ Delays were observed in the timely investigation and sign-off of serious incidents, with actions still ongoing at the time of inspection for incidents that occurred months prior.
Must-do action 27 of 32
Must do
Well-led
The service must ensure a robust audit plan is in place and key audits are conducted, including record keeping, medicines management and infection prevention and control audits. The service must ensure relevant actions identified by local audits are acted on.
Regulation: Regulation 17(1)(2)(a)(b)
⚠ Audit delays were outlined with no plans to drive improvement or action plans to monitor findings. IPC audits were inconsistent and lacked clear overall compliance data or action plans. No audits of medicines in theatre were currently undertaken despite plans.
Must-do action 28 of 32
Must do
Well-led
Senior managers must ensure robust systems and processes are in place to identify, manage, mitigate and if appropriate escalate risks. This must ensure senior managers and the board members have clear oversight of service risks.
Regulation: Regulation 17(1)(2)(a)(b)
⚠ Surgery governance committee minutes were not sufficiently detailed to ensure robust discussions on clinical risk, with scant and incomplete audit information and never events not discussed fully, indicating a lack of assured risk prioritisation and oversight.
Must-do action 29 of 32
Must do
Well-led
The service must ensure they have an up to date and robust risk register in place, and there is appropriate oversight and management of this.
Regulation: Regulation 17(1)(2)(a)(b)
⚠ Surgery governance committee minutes were not sufficiently detailed to ensure robust discussions on clinical risk, with scant and incomplete audit information and never events not discussed fully, indicating a lack of assured risk prioritisation and oversight.
Must-do action 30 of 32
Must do
Safe
The service must maintain securely an accurate, complete and contemporaneous record in respect of each service user, including a record of the care and treatment provided to the service user and of decisions taken in relation to the care and treatment provided.
Regulation: Regulation 17(2)(c)
⚠ Paper records on ward 15 had multiple loose sheets, were not filed in date order, and loose documents were placed randomly within patient files, with no locked notes trolleys, indicating unsafe and insecure management of patient records.
Must-do action 31 of 32
Must do
Well-led
The service must ensure systems or processes are established, operated and audited effectively to ensure compliance with the requirements to assess, monitor and improve the quality and safety of the services provided in the carrying on of the regulated activities.
Regulation: Regulation 17(1)(3)
⚠ Lack of auditing of the electronic system, insufficient information, and lack of oversight regarding risk meant robust governance processes were not assured, and poor performance was not fully sighted by the board with sufficient pace for improvement.
Must-do action 32 of 32
Must do
Safe
Bank and agency staff working at the hospital must receive an induction to the area(s) they are required to cover.
Regulation: Regulation 18(1)(2)(a)
⚠ Induction information for bank staff was given verbally but not formally recorded, indicating a lack of assured induction for temporary staff.

Should-do actions (12)

Recommended improvements to enhance service quality.

Should-do action 1 of 12
Should do
Well-led
The service should ensure that recent safety and performance audits for each ward are visible.
Should-do action 2 of 12
Should do
Effective
The service should ensure it can demonstrate participation in all national level audits.
Should-do action 3 of 12
Should do
Well-led
The service should ensure it has current, ongoing action plans to address the failure to meet national performance standards.
Should-do action 4 of 12
Should do
Safe
The service should ensure that confidential records are stored securely in line with national guidance.
Should-do action 5 of 12
Should do
Responsive
The service should continue to monitor the average length of stay for elective and non-elective patients to improve performance standards measured against the England average
Should-do action 6 of 12
Should do
Responsive
The service should continue to work to improve theatre utilisation.
Should-do action 7 of 12
Should do
Well-led
The service must develop a clear strategy for the health group
Should-do action 8 of 12
Should do
Well-led
The service should consider reviewing and revising the electronic system to ensure all staff have access and the system allows personalisation of care plans
Should-do action 9 of 12
Should do
Caring
The service should seek to further collate and review patient and family feedback to improve services.
Should-do action 10 of 12
Should do
Safe
The service should further develop environmental auditing to include the appropriate management of stock.
Should-do action 11 of 12
Should do
Well-led
The service should ensure that version-controlled documents are reviewed in line with service policy and national guidance.
Should-do action 12 of 12
Should do
Responsive
The service should consider how it could promote its services to minority groups to ensure its services are accessible to diverse groups.

Location details

CQC ID: RWA16
Local authority: East Riding of Yorkshire
Region: Yorkshire & Humberside

Inspection report

Type: Location
Date: 23 March 2023
Rating: Requires Improvement
Actions: 32 must-do 12 should-do
AI-extracted 3 Jun 2026

Related PFD reports

2026-0044 — Patricia Walker (Jan 2026)
2025-0041 — David Lodge (Dec 2024)
2024-0652 — Colin Wiles (Nov 2024)
2024-0255 — Linda Heath (May 2024)
2024-0076 — Ethel Reed (Feb 2024)
2024-0044 — Sylvia White (Jan 2024)
2019-0381 — Serena Nicholas (Nov 2019)