Source · CQC inspection

Glenfield Hospital

Provider University Hospitals of Leicester NHS Trust Type NHS Healthcare Organisation Region East Midlands Last inspected 10 Jun 2026

Overall rating: Requires Improvement  View full CQC report

Domain ratings

Five CQC key questions
Safe
Requires Improvement
Effective
Requires Improvement
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 10 June 2026
The service is not performing as well as it should and we have told the service how it must improve.
We carried out an unannounced focused inspection of surgical services only at Glenfield Hospital on 3, 4 and 9 June 2025. The assessment was carried out as we had concerns about the culture in cardiac surgery and the potential impact this had on patient safety. We assessed 33 quality statements across safe, effective, caring, responsive and well-led. We did not cover the full range of surgical services provided at the Glenfield Hospital. It was a focused assessment of cardiac, thoracic, vascular and hepatobiliary specialities and services. The report therefore does …

Ratings by service

Surgery
Requires Improvement
May 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 (1)

Breach Safe
We found 4 breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to safe care and treatment, environment and equipment, governance and safe staffing.
Regulation: Regulation 12 (Safe care and treatment) · 10 Jun 2026

Earlier inspection findings

pre-2024 framework · 1 must-do 12 should-do

Must-do actions (1)

Legal requirements based on regulation breaches identified during inspection.

Must-do action 1 of 1
Must do
Safe
The trust must ensure that medical devices are maintained in line with manufacturer’s recommendations.
Regulation: Regulation 12 (Safe care and treatment)
⚠ During the inspection, we checked samples of medical devices to ensure they had been serviced within the required timescales. We found several examples of where equipment must conform to had not been regularly serviced inline with the trust policy. On ward 31, there were three out of nine vital signs …

Should-do actions (12)

Recommended improvements to enhance service quality.

Should-do action 1 of 12
Should do
Well-led
The trust should ensure that their process for identifying current risks are robust.
Regulation: Regulation 17 (good governance)
Should-do action 2 of 12
Should do
Well-led
The trust should ensure all documents relating to recruitment practices are retained in line with the trust policy.
Regulation: Regulation 17 (good governance)
Should-do action 3 of 12
Should do
Well-led
The trust should ensure all Disclosure and Barring Service (DBS) checks are up-to-date and stored correctly in staff employment records.
Regulation: Regulation 17 (good governance)
Should-do action 4 of 12
Should do
Well-led
The trust should consider increasing the capacity of the Freedom To Speak Up Guardians (FTSUG) to sufficiently support all staff at the trust.
Should-do action 5 of 12
Should do
Well-led
The trust should consider continuing to improve the promotion of equality and diversity within and beyond the organisation.
Should-do action 6 of 12
Should do
Responsive
The trust should ensure that patients waiting for elective and cancer care and treatment receive this in a timely manner.
Should-do action 7 of 12
Should do
Well-led
The trust should continue its work to improve the culture throughout the trust.
Should-do action 8 of 12
Should do
Well-led
The trust should continue the work to further develop effective governance systems and processes.
Should-do action 9 of 12
Should do
Well-led
The trust should ensure that they continue to increase staffing levels by improving the recruitment and retention of nursing staff.
Regulation: Regulation 18 (good governance)
Should-do action 10 of 12
Should do
Safe
The trust should ensure that staff are trained to monitor fridge temperatures and take appropriate action if medicines have been stored outside of their required parameters.
Regulation: Regulation 12 (safe care and treatment)
Should-do action 11 of 12
Should do
Safe
The trust should ensure that full, partly full, and empty oxygen cylinders are segregated.
Regulation: Regulation 12 (safe care and treatment)
Should-do action 12 of 12
Should do
Responsive
The trust should consider improving entertainment and communication facilities for patients.

Location details

CQC ID: RWEAE
Local authority: Leicester
Region: East Midlands

Inspection report

Type: Location
Date: 25 November 2022
Rating: Requires Improvement
Actions: 1 must-do 12 should-do
AI-extracted 3 Jun 2026